Proc. 4th Congr. Int. College Psychosom. Med., Kyoto 1977 Psychother. Psychosom. 31: 59-66 (1979)
Goals of Education in Psychosomatic Medicine1 Hoyle Leigh and Morton F. Reiser Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.
Abstract. The modern concept of psychosomatic medicine is based on a multifactorial, interactional systems model for all diseases in which the behavioral and social dimensions play important roles in the pathogenesis, manifestation, course, and outcome. This psycho somatic approach forms the philosophical underpinning of a modern educational program. A general goal of education for all physicians is understanding the behavioral and psycho social factors in all illness. Specific goals for the primary physician and the psychiatrist are the instillation of a holistic attitude in patient care through systematic training, and the attainment of skills and knowledge to integrate behavioral and biomedical sciences, respec tively. This includes specific diagnostic, treatment, and educational skills. Yale’s multilevel educational program in psychosomatic medicine is described.
Three major trends in psychosomatic medicine are identifiable in the last half century in the United States. They are: (1) psychodynamic investigations into the possible role of psychologic conflicts in the pathogenesis of certain medical diseases (1) as represented by Alexander's studies; (2) the experimental and epidemiologic approach to the psychosocial factors and psychophysiology of all illnesses, and (3) consultation-liaison psychiatry, which is concerned with the application of principles and knowledge derived from psychosomatic inves tigations (4). In the past, emphasis was on the psychodynamic investigations of specific psycho logical conflicts which were thought to be one of multiple factors participating in a linear ‘psychosomatic sequence’. Accordingly, the goal of education in psychosomatic medicine was to teach young psychiatrists and physicians how to ‘recognize’ the psychosomatic diseases and the presumed specific conflicts underlying them. The role of the psychiatrist was to treat the étiologie psychologic conflicts through psychotherapy. Modern understanding of the pathogenesis of the classic ‘psychosomatic diseases’, however, indicate that specific psychologic conflicts, although contributory to the patho-
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Supported in part by USPHS Grant MH 13793-02.
Leigh/Reiser
60
Fig. 1. Comprehensive model for all diseases. From Leigh and Reiser (4), reprinted with permission. Copyright 1977 by American College of Physicians.
genesis of the disease, could by no means be considered to be always the most important factor in the etiology of the diseases in question, including peptic ulcer, essential hyper tension, ulcerative colitis, etc. Modern investigations along the experimental and epidemi ologic line have also shown that psychosocial factors are important not only in the ‘classic’ psychosomatic disorders but in all medical diseases, including cancer, infections, and so on (4). The model of the psychosomatic disease, then, changed from a linear psychosomatic one to a complex, interactions, ‘systems’ model for all diseases, with the behavioral and social dimension playing an important role not only in the pathogenesis, but also in the manifestation, course, and outcome of the illness (fig. 1).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Modern consultation-liaison psychiatry is the application of this systems model to all medical illnesses in the practice of medicine in the general hospital and in doctors’ offices. Psychiatric consultation-liaison services in teaching institutions must therefore take it upon themselves to educate future psychia trists and practicing physicians in the behavioral and psychosocial dimension of all illnesses. This is the ‘psychosomatic approach’ that forms the philosophical underpinning of the educational program in psychosomatic medicine at Yale Department of Psychiatry. Within the philosophical framework, certain general and specific goals may be defined. One general goal for both future psychiatrists and future physicians of other specialties is an understanding of the behavioral and psychosocial fac
Goals of Education in Psychosomatic Medicine
61
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
tors in all medical and psychiatric illnesses. This goal can be achieved only through an open-minded inquiring spirit, rather than dogmatic indoctrination into a particular theoretical framework. Open-mindedness also encourages new research and new ideas to illuminate the complex bio-psycho-social system. An example of this may be found in our liaison activity to the cardiology department at Yale. We found some years ago that patients with the psycho logical states of low overt hostility, high separation anxiety, and high levels of hostility directed inward as measured by the verbal sample analysis technique developed by Gottschalk and Gleser, had a higher risk of developing severe paroxysmal ventricular contractions (PVC) in the coronary care unit (CCU) (3). We also found that the physical structure of the CCU, i.e., open or closed, had subtle but significant effects on the patient’s psychological states, including levels of overt hostility and separation anxiety. Two of our psychiatric residents expanded and elaborated these findings by studying the immediate psychological contexts in which PVC occurred in the course of free associations in nonhospitalized volunteers (1, 2). We were thrilled to find that the psychological state found immediately before a run of PVC in the nonhospitalized patients was practically identical to the psychological state found in the patients with severe PVC in the coronary care unit. These findings serve to illustrate that the psychological environment of the coronary care unit has an impact on the patient’s risk for complications with practical implications for management. For example, nurses can be educated not to discourage moderate socialization in the CCU, which may tend to reduce separation anxiety. They need not be overly concerned over the expression of overt hostility, which is associated with a reduction in the PVC. High levels of hostility directed inward, a risk factor in PVC, is often associated with depression. Recognition of signs of depression by the educated medical and nursing staff can lead to appropriate psychiatric evaluation and treatment. A natural follow-up study of our findings would be a collaborative study by psychiatrists, cardiologists, and physiologists into the mechanism by which these emotional states are associated with the increased incidence of PVC. This approach of observation followed by replication and expansion, leading to collaborative research characterizes the observational, experimental, collabo rative, systems approach in psychosomatic medicine. In the past, some liaison psychiatrists were concerned about the unwillingness of medicine to ‘buy’ liaison psychiatry. We do not feel that liaison psychiatry or the psychosomatic approach has anything to ‘sell’. We learn as much as we teach through our association and collaboration with our medical colleagues, and, in this process,
Leigh/Rciser
62
the patient benefits from comprehensive care (fig. 2). This approach implies that the liaison psychiatrist teaches by providing specific expertise, such as in psycho pharmacology or personality assessment, and by providing a role model of comprehensive and systematic evaluation rather than by empty sermons on the importance of the psyche or how we should all be nice to our patients’. A specific goal in the education of the future primary physician is to instill an attitude — an attitude of treating the totality of the patient rather than just the diseased organ or tissue. Unlike being ‘nice to a patient’, acquisition of this attitude requires rigorous training in comprehensive and systematic evaluation techniques. Comprehensive evaluation of patients also requires good interviewing and communicative skills. Such a comprehensive evaluation, including that of the psychosocial-behavioral systems, naturally leads to comprehensive, systems intervention, including behavioral treatment methods when necessary. These include family therapy, psychiatric hospitalization, psychotropic drugs, hypnosis, and biofeedback, among others. The liaison psychiatrist plays a crucial role in the teaching of the comprehensive evaluative and treatment skills. Most future psychiatrists will practice psychosomatic medicine to a more or less degree. Even those who specialize in psychotherapy may, by dint of their MD degree, be asked by physicians in the community to evaluate medically ill patients with behavioral problems. Thus, a specific goal of training of the future psychiatrist is the attainment of a minimum amount of skills and knowledge as a
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Fig. 2. Consultation-liaison psychiatry.
63
Goals of Education in Psychosomatic Medicine Psycho somatic
Clinical experience on
Psychological foundation
other
grand rounds
Lectures in
electives
Clerkship
service
specialties
lr troduction to cl nical medicine Pathophysiology Physica diagnosis Behavioral and psychologic foundations of medical practice (mind, brain and body)
consultation-liaison psychiatrist. This involves learning comprehensive diagnostic and evaluative techniques as applied to medical patients with behavioral problems. The evaluation and treatment of organic brain syndromes, the use of psychotropic drugs in medically ill patients, indications for hypnotherapy and biofeedback, are among the important skills and information the future psychiatrist needs to acquire. But above all, they must learn to keep in contact with the medical colleagues without the use of concepts and jargons not essential for the operational understanding and management of patients. Yale’s educational program in psychosomatic medicine evolved over the past 5 or 6 years in an attempt to achieve the goals we have outlined. We shall now present a bird’s eye view of the specifics of our program for both future physicians and future psychiatrists as a sample of programs designed to meet the goals we proposed. The medical students are exposed to the psychosomatic approach from the very beginning, in the first year of medical school. This introductory course, the behavioral foundations of medical practice, consists of 2- to 3-hour weekly sessions lasting throughout the year (fig. 3). It has as its major objectives the understanding of the biological, psycho logical, and social aspects of the patient, and the contribution of these factors in the pathogenesis, manifestation, and course of illness. The topics covered in this course include, among others, the functions of the brain, psychotropic drugs, psychological conflicts and defenses, the sick role, the management of patients according to their personality styles. The psychophysiopathology of stress is an important theme in this course. Another major objective of this course is developing communicative skills for future physicians. An elementary introduction to linguistics and the world of
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Fig. 3. Psychosomatic medicine in medical school.
Leigh/Reiser
64
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
symbols prepares the student to the world of meanings, meanings attached to symptoms, and meanings influencing the course of physical illness. Actual interviews with patients with medical illnesses as well as video and audio tape recordings are used to facilitate this aspect of the course. In the second year of medical school, psychosomatic medicine is reintro duced to the students in their physical diagnosis and pathophysiology courses. Interviewing skills for depression, suicidality, and organic brain syndrome, among others, are taught in the context of physical diagnosis. Pathophysiology of such states as anxiety, including its brain mechanisms and its role in the pathogenesis of stress-related illnesses, is discussed in the pathophysiology course. When students reach their third year of medical school, they rotate through the clinical subspecialties such as medicine and surgery for clerkship training. The psychiatric consultation-liaison service at Yale is a clerkship site in psychia try primarily for students who are planning to enter a nonpsychiatric specialty. In this setting, the students are exposed to medical and surgical patients with behavioral problems for whom psychiatric consultation is being performed. By seeing these patients with the consultation psychiatrist, and learning how to evaluate and treat them, they leam the comprehensive psychosomatic approach to all patients. Interestingly, a number of students who had taken this rotation decided to specialize in psychiatry after all. In the fourth and final year of medical school, students may elect a specialized curriculum for future psychiatrists called the ‘psychological founda tions track’. Psychosomatic education forms a major part of the curriculum in this track through a weekly didactic seminar on psychosomatic concepts and clinical work in the consultation-liaison service. They also attend other didactic conferences offered by the service together with residents and physicians in general. The graduate education program in psychosomatic medicine has as its base: (1) the psychiatric resident’s internship experience as a primary physician; (2) experience on inpatient and outpatient services as a psychiatrist (fig. 4). Specific consultation-liaison training is available for 6-month periods during the third post-graduate year. This includes consultation and liaison work on medical and surgical services and didactic seminars and individual supervision. An emphasis during this period is to learn how to communicate with the medical staff, understanding the interaction between the bio-psycho-social systems of the patient and the hospital setting, assessment of organic brain syndromes and depression in medical patients, and psychopharmacology as applied to the
Goals of Education in Psychosomatic Medicine
Integrated seminar
Faculty
Psychosomatic Grand Rounds
includes doctors social workers PhDs students
nurses social
-------Consultation-liaison service Consultation and liaison
Internship
includes doctors
Chief resident teaching research administration
nurses
65
\ Didactic seminars j and teaching
workers PhDs students
Psychiatry Inpatient and outpatient Psychotherapy Psychopharmacology
Fig. 4. Post MD education for psychiatrists.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
medically ill. In the course of their work, they learn to teach medical staff, nurses, and other professionals the psychosomatic approach to patients. Selected residents with special interest in psychosomatic medicine serve as chief residents of the consultation-liaison service for additional 6-month periods in the fourth and final year of their residency. In addition to consultation-liaison work, the chief resident learns teaching, research, and administrative skills. They are prepared for an academic or administrative career in psychosomatic medicine. There are a number of didactic and clinical conferences designed to meet the educational needs of interdisciplinary groups. Psychosomatic Grand Rounds, held weekly, are open to all members of the medical community at Yale, including primary physicians, practicing psychiatrists, social workers, nurses, and psychologists. Cases are usually presented to a senior psychiatrist and a senior member of a nonpsychiatric department, such as neurology, surgery, or medicine. The patients are interviewed and the cases discussed by the psychia trist and the primary physician, with a view toward integration of expertise for patient care. Special guest lectures, research presentations, and topic-oriented discussions also occur in Psychosomatic Grand Rounds. The Integrated Seminar on Psychosomatic Medicine is a didactic conference primarily geared toward the psychiatric residents and advanced medical students. Major concepts, research findings, and syndromes pertinent to psychosomatic medicine are discussed in a systematic fashion. The topics include, among others, the nature and management of pain, anxiety, hysteria, hypnosis, biofeedback, the interaction between psychotropic drugs and other medications, the assess
Leigh/Reiser
66
ment and management of organic brain syndromes, etc. In addition, there are a number of other conferences for residents, students, and physicians and nurses on specific floors of the hospital. The liaison psychiatrists also participate as discussants and lecturers in the grand rounds of other departments such as surgery and medicine. Education in research is important if psychosomatic medicine is to remain an open system that continues to develop. A number of research projects are carried out by our faculty and residents. They include, among others, psychophysiologic studies, and studies concerning effectiveness of consultation, supported by strong basic research teams in the Department of Psychiatry including neurobiology, psychoanalysis, and pharmacology. The Yale Center for Research and Education in Behavioral Medicine, a collaborative venture between the Psychiatric Consultation-Liaison Service, Department of Psychiatry, and a number of other departments including psychology, medicine, epidemiology and sociology, serves to facilitate and stimulate research in psychosomatic-behavioral medicine. In essence, the goals of psychosomatic education at Yale are the integration of biomedical and behavioral science knowledge and skills in comprehensive systems evaluation and management of patients in their bio-psycho-social dimen sions. To achieve these goals, educational programs in psychosomatic medicine must have a strong base in medicine and behavioral sciences, with integration occurring at every level of training. References
3
4
5
Alexander, F.: Psychosomatic medicine (Norton, New York 1950). Berger, F.K.; Docherty, J.P.; Oradei, D., and Leigh, H.: Psychological factors associated with premature ventricular contractions. A controlled study. Presented at the 4th Congress of the International College of Psychosomatic Medicine, Kyoto 1977. D ocherty, J.P.; Leigh, H., and David, P.: The imm ediate psychological c ontext o f
premature ventricular contractions (brief communication). Psychosom. Med. 36: 461-462 (1974). Leigh, H.; Hofer, M.; Cooper, J., and Reiser, M.: A psychological comparison of patients in ‘open’ and ‘closed’ coronary care units. J. psychosom. Res. 16: 449-457 (1972). Leigh, H. and Reiser, M.: Major trends in psychosomatic medicine. The psychiatrist’s evolving role in medicine. Ann. intern. Med. 87: 233-239 (1977). Hoyle Leigh, MD, Chief, Psychiatric Consultation-Liaison Services, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
1 2
Goals of Education in Psychosomatic Medicine1 Hoyle Leigh and Morton F. Reiser Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.
Abstract. The modern concept of psychosomatic medicine is based on a multifactorial, interactional systems model for all diseases in which the behavioral and social dimensions play important roles in the pathogenesis, manifestation, course, and outcome. This psycho somatic approach forms the philosophical underpinning of a modern educational program. A general goal of education for all physicians is understanding the behavioral and psycho social factors in all illness. Specific goals for the primary physician and the psychiatrist are the instillation of a holistic attitude in patient care through systematic training, and the attainment of skills and knowledge to integrate behavioral and biomedical sciences, respec tively. This includes specific diagnostic, treatment, and educational skills. Yale’s multilevel educational program in psychosomatic medicine is described.
Three major trends in psychosomatic medicine are identifiable in the last half century in the United States. They are: (1) psychodynamic investigations into the possible role of psychologic conflicts in the pathogenesis of certain medical diseases (1) as represented by Alexander's studies; (2) the experimental and epidemiologic approach to the psychosocial factors and psychophysiology of all illnesses, and (3) consultation-liaison psychiatry, which is concerned with the application of principles and knowledge derived from psychosomatic inves tigations (4). In the past, emphasis was on the psychodynamic investigations of specific psycho logical conflicts which were thought to be one of multiple factors participating in a linear ‘psychosomatic sequence’. Accordingly, the goal of education in psychosomatic medicine was to teach young psychiatrists and physicians how to ‘recognize’ the psychosomatic diseases and the presumed specific conflicts underlying them. The role of the psychiatrist was to treat the étiologie psychologic conflicts through psychotherapy. Modern understanding of the pathogenesis of the classic ‘psychosomatic diseases’, however, indicate that specific psychologic conflicts, although contributory to the patho-
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Supported in part by USPHS Grant MH 13793-02.
Leigh/Reiser
60
Fig. 1. Comprehensive model for all diseases. From Leigh and Reiser (4), reprinted with permission. Copyright 1977 by American College of Physicians.
genesis of the disease, could by no means be considered to be always the most important factor in the etiology of the diseases in question, including peptic ulcer, essential hyper tension, ulcerative colitis, etc. Modern investigations along the experimental and epidemi ologic line have also shown that psychosocial factors are important not only in the ‘classic’ psychosomatic disorders but in all medical diseases, including cancer, infections, and so on (4). The model of the psychosomatic disease, then, changed from a linear psychosomatic one to a complex, interactions, ‘systems’ model for all diseases, with the behavioral and social dimension playing an important role not only in the pathogenesis, but also in the manifestation, course, and outcome of the illness (fig. 1).
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Modern consultation-liaison psychiatry is the application of this systems model to all medical illnesses in the practice of medicine in the general hospital and in doctors’ offices. Psychiatric consultation-liaison services in teaching institutions must therefore take it upon themselves to educate future psychia trists and practicing physicians in the behavioral and psychosocial dimension of all illnesses. This is the ‘psychosomatic approach’ that forms the philosophical underpinning of the educational program in psychosomatic medicine at Yale Department of Psychiatry. Within the philosophical framework, certain general and specific goals may be defined. One general goal for both future psychiatrists and future physicians of other specialties is an understanding of the behavioral and psychosocial fac
Goals of Education in Psychosomatic Medicine
61
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
tors in all medical and psychiatric illnesses. This goal can be achieved only through an open-minded inquiring spirit, rather than dogmatic indoctrination into a particular theoretical framework. Open-mindedness also encourages new research and new ideas to illuminate the complex bio-psycho-social system. An example of this may be found in our liaison activity to the cardiology department at Yale. We found some years ago that patients with the psycho logical states of low overt hostility, high separation anxiety, and high levels of hostility directed inward as measured by the verbal sample analysis technique developed by Gottschalk and Gleser, had a higher risk of developing severe paroxysmal ventricular contractions (PVC) in the coronary care unit (CCU) (3). We also found that the physical structure of the CCU, i.e., open or closed, had subtle but significant effects on the patient’s psychological states, including levels of overt hostility and separation anxiety. Two of our psychiatric residents expanded and elaborated these findings by studying the immediate psychological contexts in which PVC occurred in the course of free associations in nonhospitalized volunteers (1, 2). We were thrilled to find that the psychological state found immediately before a run of PVC in the nonhospitalized patients was practically identical to the psychological state found in the patients with severe PVC in the coronary care unit. These findings serve to illustrate that the psychological environment of the coronary care unit has an impact on the patient’s risk for complications with practical implications for management. For example, nurses can be educated not to discourage moderate socialization in the CCU, which may tend to reduce separation anxiety. They need not be overly concerned over the expression of overt hostility, which is associated with a reduction in the PVC. High levels of hostility directed inward, a risk factor in PVC, is often associated with depression. Recognition of signs of depression by the educated medical and nursing staff can lead to appropriate psychiatric evaluation and treatment. A natural follow-up study of our findings would be a collaborative study by psychiatrists, cardiologists, and physiologists into the mechanism by which these emotional states are associated with the increased incidence of PVC. This approach of observation followed by replication and expansion, leading to collaborative research characterizes the observational, experimental, collabo rative, systems approach in psychosomatic medicine. In the past, some liaison psychiatrists were concerned about the unwillingness of medicine to ‘buy’ liaison psychiatry. We do not feel that liaison psychiatry or the psychosomatic approach has anything to ‘sell’. We learn as much as we teach through our association and collaboration with our medical colleagues, and, in this process,
Leigh/Rciser
62
the patient benefits from comprehensive care (fig. 2). This approach implies that the liaison psychiatrist teaches by providing specific expertise, such as in psycho pharmacology or personality assessment, and by providing a role model of comprehensive and systematic evaluation rather than by empty sermons on the importance of the psyche or how we should all be nice to our patients’. A specific goal in the education of the future primary physician is to instill an attitude — an attitude of treating the totality of the patient rather than just the diseased organ or tissue. Unlike being ‘nice to a patient’, acquisition of this attitude requires rigorous training in comprehensive and systematic evaluation techniques. Comprehensive evaluation of patients also requires good interviewing and communicative skills. Such a comprehensive evaluation, including that of the psychosocial-behavioral systems, naturally leads to comprehensive, systems intervention, including behavioral treatment methods when necessary. These include family therapy, psychiatric hospitalization, psychotropic drugs, hypnosis, and biofeedback, among others. The liaison psychiatrist plays a crucial role in the teaching of the comprehensive evaluative and treatment skills. Most future psychiatrists will practice psychosomatic medicine to a more or less degree. Even those who specialize in psychotherapy may, by dint of their MD degree, be asked by physicians in the community to evaluate medically ill patients with behavioral problems. Thus, a specific goal of training of the future psychiatrist is the attainment of a minimum amount of skills and knowledge as a
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Fig. 2. Consultation-liaison psychiatry.
63
Goals of Education in Psychosomatic Medicine Psycho somatic
Clinical experience on
Psychological foundation
other
grand rounds
Lectures in
electives
Clerkship
service
specialties
lr troduction to cl nical medicine Pathophysiology Physica diagnosis Behavioral and psychologic foundations of medical practice (mind, brain and body)
consultation-liaison psychiatrist. This involves learning comprehensive diagnostic and evaluative techniques as applied to medical patients with behavioral problems. The evaluation and treatment of organic brain syndromes, the use of psychotropic drugs in medically ill patients, indications for hypnotherapy and biofeedback, are among the important skills and information the future psychiatrist needs to acquire. But above all, they must learn to keep in contact with the medical colleagues without the use of concepts and jargons not essential for the operational understanding and management of patients. Yale’s educational program in psychosomatic medicine evolved over the past 5 or 6 years in an attempt to achieve the goals we have outlined. We shall now present a bird’s eye view of the specifics of our program for both future physicians and future psychiatrists as a sample of programs designed to meet the goals we proposed. The medical students are exposed to the psychosomatic approach from the very beginning, in the first year of medical school. This introductory course, the behavioral foundations of medical practice, consists of 2- to 3-hour weekly sessions lasting throughout the year (fig. 3). It has as its major objectives the understanding of the biological, psycho logical, and social aspects of the patient, and the contribution of these factors in the pathogenesis, manifestation, and course of illness. The topics covered in this course include, among others, the functions of the brain, psychotropic drugs, psychological conflicts and defenses, the sick role, the management of patients according to their personality styles. The psychophysiopathology of stress is an important theme in this course. Another major objective of this course is developing communicative skills for future physicians. An elementary introduction to linguistics and the world of
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
Fig. 3. Psychosomatic medicine in medical school.
Leigh/Reiser
64
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
symbols prepares the student to the world of meanings, meanings attached to symptoms, and meanings influencing the course of physical illness. Actual interviews with patients with medical illnesses as well as video and audio tape recordings are used to facilitate this aspect of the course. In the second year of medical school, psychosomatic medicine is reintro duced to the students in their physical diagnosis and pathophysiology courses. Interviewing skills for depression, suicidality, and organic brain syndrome, among others, are taught in the context of physical diagnosis. Pathophysiology of such states as anxiety, including its brain mechanisms and its role in the pathogenesis of stress-related illnesses, is discussed in the pathophysiology course. When students reach their third year of medical school, they rotate through the clinical subspecialties such as medicine and surgery for clerkship training. The psychiatric consultation-liaison service at Yale is a clerkship site in psychia try primarily for students who are planning to enter a nonpsychiatric specialty. In this setting, the students are exposed to medical and surgical patients with behavioral problems for whom psychiatric consultation is being performed. By seeing these patients with the consultation psychiatrist, and learning how to evaluate and treat them, they leam the comprehensive psychosomatic approach to all patients. Interestingly, a number of students who had taken this rotation decided to specialize in psychiatry after all. In the fourth and final year of medical school, students may elect a specialized curriculum for future psychiatrists called the ‘psychological founda tions track’. Psychosomatic education forms a major part of the curriculum in this track through a weekly didactic seminar on psychosomatic concepts and clinical work in the consultation-liaison service. They also attend other didactic conferences offered by the service together with residents and physicians in general. The graduate education program in psychosomatic medicine has as its base: (1) the psychiatric resident’s internship experience as a primary physician; (2) experience on inpatient and outpatient services as a psychiatrist (fig. 4). Specific consultation-liaison training is available for 6-month periods during the third post-graduate year. This includes consultation and liaison work on medical and surgical services and didactic seminars and individual supervision. An emphasis during this period is to learn how to communicate with the medical staff, understanding the interaction between the bio-psycho-social systems of the patient and the hospital setting, assessment of organic brain syndromes and depression in medical patients, and psychopharmacology as applied to the
Goals of Education in Psychosomatic Medicine
Integrated seminar
Faculty
Psychosomatic Grand Rounds
includes doctors social workers PhDs students
nurses social
-------Consultation-liaison service Consultation and liaison
Internship
includes doctors
Chief resident teaching research administration
nurses
65
\ Didactic seminars j and teaching
workers PhDs students
Psychiatry Inpatient and outpatient Psychotherapy Psychopharmacology
Fig. 4. Post MD education for psychiatrists.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
medically ill. In the course of their work, they learn to teach medical staff, nurses, and other professionals the psychosomatic approach to patients. Selected residents with special interest in psychosomatic medicine serve as chief residents of the consultation-liaison service for additional 6-month periods in the fourth and final year of their residency. In addition to consultation-liaison work, the chief resident learns teaching, research, and administrative skills. They are prepared for an academic or administrative career in psychosomatic medicine. There are a number of didactic and clinical conferences designed to meet the educational needs of interdisciplinary groups. Psychosomatic Grand Rounds, held weekly, are open to all members of the medical community at Yale, including primary physicians, practicing psychiatrists, social workers, nurses, and psychologists. Cases are usually presented to a senior psychiatrist and a senior member of a nonpsychiatric department, such as neurology, surgery, or medicine. The patients are interviewed and the cases discussed by the psychia trist and the primary physician, with a view toward integration of expertise for patient care. Special guest lectures, research presentations, and topic-oriented discussions also occur in Psychosomatic Grand Rounds. The Integrated Seminar on Psychosomatic Medicine is a didactic conference primarily geared toward the psychiatric residents and advanced medical students. Major concepts, research findings, and syndromes pertinent to psychosomatic medicine are discussed in a systematic fashion. The topics include, among others, the nature and management of pain, anxiety, hysteria, hypnosis, biofeedback, the interaction between psychotropic drugs and other medications, the assess
Leigh/Reiser
66
ment and management of organic brain syndromes, etc. In addition, there are a number of other conferences for residents, students, and physicians and nurses on specific floors of the hospital. The liaison psychiatrists also participate as discussants and lecturers in the grand rounds of other departments such as surgery and medicine. Education in research is important if psychosomatic medicine is to remain an open system that continues to develop. A number of research projects are carried out by our faculty and residents. They include, among others, psychophysiologic studies, and studies concerning effectiveness of consultation, supported by strong basic research teams in the Department of Psychiatry including neurobiology, psychoanalysis, and pharmacology. The Yale Center for Research and Education in Behavioral Medicine, a collaborative venture between the Psychiatric Consultation-Liaison Service, Department of Psychiatry, and a number of other departments including psychology, medicine, epidemiology and sociology, serves to facilitate and stimulate research in psychosomatic-behavioral medicine. In essence, the goals of psychosomatic education at Yale are the integration of biomedical and behavioral science knowledge and skills in comprehensive systems evaluation and management of patients in their bio-psycho-social dimen sions. To achieve these goals, educational programs in psychosomatic medicine must have a strong base in medicine and behavioral sciences, with integration occurring at every level of training. References
3
4
5
Alexander, F.: Psychosomatic medicine (Norton, New York 1950). Berger, F.K.; Docherty, J.P.; Oradei, D., and Leigh, H.: Psychological factors associated with premature ventricular contractions. A controlled study. Presented at the 4th Congress of the International College of Psychosomatic Medicine, Kyoto 1977. D ocherty, J.P.; Leigh, H., and David, P.: The imm ediate psychological c ontext o f
premature ventricular contractions (brief communication). Psychosom. Med. 36: 461-462 (1974). Leigh, H.; Hofer, M.; Cooper, J., and Reiser, M.: A psychological comparison of patients in ‘open’ and ‘closed’ coronary care units. J. psychosom. Res. 16: 449-457 (1972). Leigh, H. and Reiser, M.: Major trends in psychosomatic medicine. The psychiatrist’s evolving role in medicine. Ann. intern. Med. 87: 233-239 (1977). Hoyle Leigh, MD, Chief, Psychiatric Consultation-Liaison Services, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 (USA)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/25/2018 6:17:09 PM
1 2
