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Psychodynamic Social Science and Medical Education

Address correspondence to Dr. Marcus, Columbia University Department of Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #125, New York, NY 10032.

Key Words: Psychodynamic Social Science • Medical Education • Psychotherapy Training

	Introduction

Top Introduction PSYCHODYNAMIC RESEARCH DATA RESULTS APPLICATION OF THIS FINDING... LESSONS LEARNED References

 
Psychoanalysis and psychodynamics can offer medical education an understanding of unconscious emotional developmental processes. This knowledge can not only guide teachers and mentors in individual teaching tasks, but also enable us to understand medical students' growth and development in the professionalization process. Understanding how students become professionalized can help us understand the effect of medical education on the process. This can then perhaps help us influence medical pedagogy so that our courses and our teaching approaches benevolently steer the professionalization process in directions we value.

Medical education is an emotional developmental process and not just a process of information transfer. You don't only learn facts; you become a doctor. Becoming a doctor describes a state of being, a state of feeling about ourselves that suggests a set of self-representations whose organization and content we call professional identity. We are in the infancy of trying to understand the processes at work in the organization of professional identity.

Clearly, major aspects of this identity formation occur in medical school. Many of us psychodynamic educators have hypothesized, on the basis of personal experience and observation, that pedagogy in medical school is affecting professional identity through processes of identification in students. If this is true, how we teach is also what we teach and may be more important than content teaching. From the medical students' point of view, medical school experiences are at least as important in professional identity formation as the facts they are taught.

What are the developmental vicissitudes of this unconscious professionalization process? How does pedagogy in medical school affect unconscious professionalization? Should we change medical pedagogy, and if so, how? Freud said he hoped psychoanalysis would influence pedagogy but added that whether the result would be for better or worse he could not say!

	PSYCHODYNAMIC RESEARCH DATA

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The problem in exploring this issue is how to get data that reveal unconscious, developmental psychodynamic processes. I have chosen to study this issue by collecting dreams students have had where the manifest content is about medical school. The collection in this study was from medical students at one major academic medical school. The dream collection was done over several contiguous years. The study population was a convenience sample of volunteers who submitted their dreams for remuneration of $10.00 per dream. None was undergoing psychiatric treatment. The submissions were anonymous and gave only the manifest content of the dream, the sex of the dreamer, and the year of medical school or residency training in which the dream occurred. The dream collection covers all years of training from medical school year 1 through the last year of residency. The dreams are not dreamt by a collection of dreamers who dream over the years but are from volunteer cohorts in each year. The collection is from the different years of training simultaneously collected. I purposely did not want the same cohort progressing through all the years, because I was less interested in the individual developmental process than in the group's, and I believed that the individual variants would more easily be washed out by collecting different individuals from the training sequence. In this way, I hoped to accentuate the themes of each year rather than the themes of the individual dreamer.

The dreams were studied in two ways. The first way was to read them serially to see if a sequential unconscious fantasy was thereby revealed. The second was to analyze the dream symbols according to categories of character, setting, action, specific medical school day residue, and affect. Each dream was cross-catalogued according to these categories, and the entire collection of about 400 dreams was placed on computer disk along with the categories. This spreadsheet approach to the tracking of the dream symbols enabled simple statistical measures to be done for each dream symbol as it changed year by year. The statistics produced served as a rough approximate gauge of accuracy of the hypothesized unconscious fantasy, as well as suggesting aspects of that fantasy.

	RESULTS

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The research result most pertinent for this paper is the vicissitudes of empathy and emotional involvement with patients, because this is a crucial area in which psychodynamically trained medical school teachers can contribute. Achieving an appropriate level of empathy is one of the major psychological tasks of medical training. The major finding in the dream material is the sequence of close identification with patients in the early years of medical training followed immediately by a flooding of that identification due to the intense, traumatic emotional experience of feeling so much like desperately ill patients, or even the cadaver, that the student is in danger of experiencing what is happening to the patient or the cadaver as happening to themselves. This flooding, reflected in traumatic nightmares of identification, is delivered by medical school training experiences in the form of abrupt, overwhelming experiences for which there is no emotional preparation. It results in a series of counteridentifications against patient experience and in favor of identifications with faculty. It is the psychodynamic explanation for why students in the first year of medical school can interview a patient and show great understanding of the patient's emotional experience although having little knowledge of biological illness, whereas in the fourth year of medical school they can interview patients with great understanding of biological illness but little understanding of the patient's emotions.¹ The ability to empathize with patients in the student's object representations rather than identify with patients in the student's self-representation is a psychological ability that only becomes solidified and relatively resilient in later years of residency training.

	APPLICATION OF THIS FINDING TO MEDICAL PEDAGOGY

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Can we use this basic finding to consider whether medical school education can decrease its traumatic impact on students and solidify an empathic ability earlier in medical training? Can this grow out of more benign medical school experience as well as be the result of direct, didactic teaching in the area of empathy? There are data to show that factual information does not change student attitudes.² It might therefore be worth trying the experiential model.

Over the last several years, I was given administrative and pedagogical responsibility for all the non-basic science courses at the College of Physicians and Surgeons at Columbia University. I tried to use this dream study to fashion an integrated sequence of courses in the doctor-patient relationship, ethics and values, clinical epidemiology, human nutrition, human sexuality, life cycle development, pathophysiology correlation clinics, medical interviewing, physical examination of the patient, and psychiatry.

The courses are conceived as a sequence for teaching, illustrating, and demonstrating skills in the doctor-patient relationship, applied to patients undergoing illness in the context of the life cycle and in the context of the life cycle of the physician. The central early medical student fantasy of one doctor, one patient, one responsibility, one goal, one illness, one fact, one intervention, one cure is acknowledged and elaborated, but it is also made more complex by reference to the viewpoints of other disciplines and to the complexity of the doctor-patient relationship.

Caring and empathy are taught directly through medical interviewing courses and in discussions on the psychology of medical care. Specific skills and attitudes are modeled, as well as taught, within the confines of the student's knowledge base. In the first year, when knowledge about biological illness processes is small and skills in specific medical history taking are weak but listening attitude is high, students are taught to elicit patients' life histories, of which the illness is only a part. Students are shown the power of listening to stories and of telling the story back to the patient. A sequence in the humanities on narrative structures is a selective available to students in the second year that elaborates this skill.

Teaching is done with live patients from day one, liberating the student from the psychology of having the cadaver as the first "patient" experience.

In the organization of our courses, we are trying to change the focus of medical education from data stuffing and data sponging, with its underlying fantasy that it is possible to learn an infinite data set, to a focus on processes both within people and within data sets. The clinical approach is taught as above all a collection of observational skills about operational processes and principles. We try to decrease the emphasis on competitive fact grabbing and grade grubbing and emphasize student doctors' unique roles in an individual's life because of their power to connect with the individual, not because of their competitive ability to get a better grade within their group of peers.

We try to help them understand that their fantasy of the "fact that they don't know" killing someone and the "fact that they do know" saving someone is a greatly exaggerated fantasy. The reality is that the better emotional contact you have with someone, the greater the bond of trust, the more pertinent clinical facts will be given to you by the patient, and the better chance you will have of seeing the integrative illness processes and of judging the appropriate intervention. It isn't the facts only, it's the relationship of the facts: the process.

We hope that in this way we can make an impact on the learning environment so that students will feel better taken care of by us as a faculty and by their peers, and that this sense of being cared for will enable a better attitude of care taking. We try to influence the content of student identifications by not flooding them with patient experience and by providing a benevolent role model in faculty rather than seeming distant, judgmental, and unemotional. We attempt to teach in a cross-disciplinary way that shows the integration of knowledge as well as its dissection. We illustrate the integration of life histories and illness histories. We try to ameliorate the dissection experience by having an elective in life drawing where students can look at, experience, and try to render on the page the living anatomy of function, of form, and of aesthetic. We find students better able to tolerate integrative experiences involving the dynamic living and healthy rather than the sick and the dead.

In order to encourage an integrative experience of medical school, encompassing both the intellectual and the emotional, we give the students a journal consisting of a hard-cover blank book with a seal of the school and the year of their class. They are encouraged to write about their experiences in medical school, both of patients and of themselves.

These journals, the course content, and their patient care experiences are discussed in weekly small-group teaching with clinical mentors. The clinicians are volunteers whose backgrounds are in clinical practice, in public health, and in teaching. They are a devoted group of practicing doctors from all specialties. They are empathic mentors who help the students integrate and digest data, cooperate and help each other, and learn basic clinical skills and the relevance of basic science facts to those clinical skills. The emphasis is on processes of learning, processes of interpersonal contact, and the organization, relevance, and application of knowledge in the clinical setting.³ At all times, patience, interest, concern, validation, and encouragement are demonstrated by the mentors. Sometimes this mentoring concern involves tactfully but fearlessly dealing with the more aggressive students. These moments are some of the crucial educational moments both for the individual whose behavior is inappropriate and for the small group as a whole.

	LESSONS LEARNED

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We think we are learning the importance of faculty concern about patients and patient care, students and student care, curriculum, and student learning environments. We are appreciating the need for faculty development directed toward an increasingly psychologically sophisticated view of pedagogy. We help each other with this development through faculty meetings, faculty discussions, and faculty reading. We share teaching techniques, try out each other's pedagogical methods, develop our own styles, see what works and what doesn't, and try to shape the course to our growing experience with the course. We are more and more convinced that active learning—the teaching of specific skills and attitudes through the modeling and mentoring function of the small group leader—is empowering students both intellectually and emotionally.

We take great care not to traumatize students by flooding them with data or by flooding them with clinical experiences that they don't have a chance to prepare themselves for and discuss afterward. We try never to show off or to humiliate a student, even when we have to defuse a student's grandiose certainty that he or she knows it all.

Our outcome data are outstanding. Student satisfaction with these courses has risen from very dissatisfied to outstandingly satisfied. The faculty involved with the course have appreciated the organized focus on the clinical approach and on clinical values. The third-year clerkship teachers feel that students enter the clerkship at a higher level of sophistication about people and about the clinical task and do better interviews, physical exams, and case formulations. Nevertheless, the long-range staying power of these benevolent experiences and their capacity to influence the longer range developmental course during clerkship, senior subinternship, internship, and residency training remain to be tested.

If these changes are effective and durable, it will demonstrate the usefulness of the psychodynamic approach to the social science of medical pedagogy that focuses on the unconscious professionalization process. This field of study is another of the rewards available to the psychoanalytically informed medical school faculty member.

	References

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1. Helfer A: An objective comparison of the pediatric interviewing skills of the freshman and senior medical student. Pediatrics 1970; 45:623–627[Abstract/Free Full Text]
2. Bernstein CA, Rabkin JG, Wolland H: Medical and dental students' attitudes about the AIDS epidemic. Acad Med 1990; 65:458–460[Medline]
3. Marcus ER: The role of liaison psychiatry in the clinical training of medical students: a psychoanalytic approach, in Consultation-Liaison Psychiatry: Current Trends and New Perspectives. New York, Grune and Stratton, 1983, pp 267–284

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