dcpsychresidents : Message: PSYCHIATRIC RESIDENTS AS TEACHERS: A PRACTICAL GUIDE

PSYCHIATRIC RESIDENTS AS TEACHERS: A PRACTICAL GUIDE

Committee on Graduate Education 2001-2002

INTRODUCTION

In your role as a psychiatric resident, teaching has already become one of your many responsibilities. You may have approached this new role with a mixture of excitement, enthusiasm, and trepidation. While teaching is often recognized as an important part of residency, few programs offer formalized didactics or workshops to improve teaching by residents. This disparity led to the development of this booklet, prepared by the American Psychiatric Association and designed to help psychiatry residents become better teachers. It is organized into the following sections:

1) The importance of teaching residents to teach

2) The benefits of teaching

3) Teaching opportunities

4) General teaching principles

5) Giving feedback and evaluating students

6) Unique issues for psychiatric residents as teachers.

THE IMPORTANCE OF TEACHING RESIDENTS TO TEACH

Whether you work in an academic or clinical setting, you will continue to teach throughout your career. Psychiatrists frequently teach medical students, patients, physicians, other health professionals, and the public. Residents in particular play an extremely important role in the teaching of medical students. According to one study, residents spend 20% to 25% of their time teaching students (Brown 1970). Surveys of medical students estimate one-third of their clinical learning is taught by residents (Barrow 1966, Bing-You and Sproul 1992) and residents are recognized as important and influential teachers (Edwards and Marier 1988, Schumway et al 1988, Schwartz et al 1991, Schwenk and Whitman 1984). Additionally, residents serve as role models and, as such, have a clear influence on specialty choice among medical students (Schumway et al 1988, Schwartz et al 1991). With the rapid changes in the healthcare system in the twenty first century, the role of residents in teaching medical students will become even more crucial.

Recognizing the importance of teaching and residents as teachers, the Special Requirements for Residency Training in Psychiatry list the "ability to teach psychiatry to students in the health professions" as a requisite skill to be attained during residency. Despite this, instruction in teaching is often neglected. Most residents receive no formal training designed to make them better teachers (Callen and Roberts 1980) and a national survey showed that only 20% of internal medicine programs had teaching skills improvement programs (Bing-You and Tooker 1993). Most residents surveyed reported they would like to receive training to develop and improve their teaching skills (Roberts et al 1994).

Teaching is therefore an important skill residents will use throughout their careers, but a skill that must be learned. Residency provides an excellent opportunity for residents to focus on and hone their teaching skills. This booklet is designed to assist in that process.

THE BENEFITS OF TEACHING

Benefits to medical students

Resident teaching provides a level of knowledge and experience intermediate between that of students and faculty.
While students may feel intimidated by attendings and thus retreat into a more passive learning style, they are generally more willing to ask questions of and look for guidance from residents. Residents are closer to the medical student experience and better able to understand particular students� needs.
Residents can often better discern where students are having difficulty with a particular case or concept. Also, residents can help students deal with common areas of stress and anxiety, e.g., being on call, exams, or writing orders. Residents have a powerful influence on students� views of psychiatry as a field.
Research has found that many students view psychiatry as a less attractive career compared to other medical specialties (Feifel et al., 1999). Students frequently hold inaccurate beliefs about the efficacy of psychiatric treatments and about future prospects for psychiatry as a field. Residents are in a unique position to address and dispel these inaccuracies (see Unique Issues below).

Benefits to residents

Teaching hones skills you will use throughout your career
You will continue to use these skills to teach patients, other physicians, community groups, residents, medical students, etc. Teaching leads to an improved fund of knowledge.
In conveying concepts to students, you must organize and review your own knowledge. Questions from students can help identify gaps in your knowledge base. Teaching helps you acquire skills needed for lifelong learning.
As we become more "advanced" in our approach to clinical problem-solving, we often lose sight of the basics. Students� more basic problem-solving strategies force us to make our thought processes explicit and promote more reliable learning strategies. Thus, in the process of teaching, residents "learn how to learn" (Steward and Feltovich, 1988). Teaching allows residents to influence students� approaches to medicine and even their career choice.
Excellence in teaching, along with clinical skills and personal attributes, is an important characteristic affecting career choice among medical students. Also, medical students are more likely to model their own interactions with patients after teachers they respect and admire. Psychiatry residents are in a particularly privileged position to promote a life-long, self-directed process of self-reflection and awareness among medical students.
Residents can offer candid discussions and appropriate self-disclosure to medical students to foster an awareness of unconscious feelings, emotions, behaviors, beliefs, and attitudes evoked by the care of individual patients.

TEACHING OPPORTUNITIES

The beginning of the clerkship

Make sure students know the objectives and expectations of the clerkship. On the first day of the rotation, clarify working arrangements and guidelines; be as specific as possible about what students are expected to do.
Help students become accustomed to the rotation.
Students are usually unfamiliar with procedures that seem basic to you. For example, providing students with an outline of how to write a daily progress note on a psychiatry service � and giving examples to follow � can alleviate much anxiety. Also, the terminology used in the mental status examination often needs to be clarified; use real patient examples when possible. Help students become more comfortable with psychiatric patients.
Many students are initially uncomfortable with psychiatric patients. Over the first few days of the rotation, accompany students to meet their patients. First, have them observe interviews, then have them interview while you observe. Connect the psychiatry rotation to students� particular interests and goals.
Make an effort to show how psychiatry connects with students� interests, recognizing that most students will not choose psychiatry as a career. Show interest and respect for a student�s particular career path; help students learn how psychiatry can be beneficial to them. Keep in mind that most students are curious and want to learn � this curiosity can be tapped by creative teachers.

Interviewing

Help students structure their approach to the interview. Beforehand, discuss the purpose of the interview and what information needs to be obtained. Afterwards, discuss what happened and review the interviewer�s ability to develop rapport and elicit appropriate biopsychosocial data.
Identify and reinforce what students do well and discuss where improvements might be made
Encourage students to discuss problems encountered when interviewing. Use open-ended questions, e.g., "How did it go with Mr. A?", and remain non-judgemental. (See section on giving feedback.) Help students become aware of and use their emotional reactions to the patient.
While some students may be better able to engage psychodynamic issues, students going into any field in medicine should learn how patients� affect and behavior derive from underlying mood or cognitive states � and how these states are often reflected by a student�s own reactions. Having such a discussion with a student does not imply that residents should delve into students� own conflicts or issues. Expose students to a variety of interview styles and techniques.
When reviewing a faculty or resident interview, discuss reasons for conducting the interview in a particular manner and why certain techniques were used. Particulary, students should see techniques used to interview angry, disorganized, psychotic, and confused patients. If actual patients are not available, consider using videotaped or audiotaped interviews.

Mental status exam

Explain the various parts of the exam and demonstrate how to ascertain this information. Be aware that some students may associate the mental status exam solely with tests of cognitive function.
Encourage students to summarize the key elements of the mental status exam on an index card.
This can provide a guide during interviewing, help them organize the material for presentations, and provide a template to use when writing progress notes. Use the mental status exam to demonstrate different forms of psychopathology.
Videotapes demonstrating particular mental status pathology are very helpful when clinical material is not available or to expand on actual patient experiences.

Case presentations

Teach students to present in a concise, well-organized manner. Encourage students to give presentation that clearly describe the patient, pertinent history, key issues in the case, and clinical decision-making. Be sure your own case presentations demonstrate an organized, logical presentation style.
Encourage students to outline the major categories of the presentation on an index card.
Students can then use this until they gain more experience and confidence. Prior to the first presentation, have students practice with you.

Formulating cases

Teach students to formulate a patient�s problem in a complete, organzied way. Help students summarize the factors that contributed to the patient becoming ill, including developmental factors, current life situation, social supports and constitutional factors.
Avoid using jargon in formulations.

Diagnosis

Diagnoses should follow DSM-IV criteria and nomenclature.
Encourage students to develop a complete differential diagnosis. Students may deal with ambiguity by arriving too quickly at a diagnosis or by avoiding committing themselves to a primary diagnosis. Help students explore multiple diagnoses and how they do or don�t fit the clinical picture.
Encourage students to develop working diagnoses and to devise strategies to test their hypotheses.
Ask students what further data need to be collected to make a diagnosis.
Use DSM-IV multi-axial nomenclature as a springboard to reinforce the biopsychosocial model of disease.
Axis II diagnoses often lead to a discussion of developmental issues. Axis III requires students to consider concomitant medical problems. Axis IV necessitates the integration of psychosocial stressors and environmental factors impinging on the patient. Axis V can be used to focus discussion on the patient�s current functioning and prognosis.

Treatment

Have the student outline what treatments would be helpful. If choosing a medication, discuss side effects and contraindications.
Psychotherapeutic interventions should be discussed with careful consideration of the criteria for selecting treatment.
Details of psychotherapeutic interventions are often beyond the scope of the usual clerkship, although there may be exceptions. Encourage students to explore other possible therapies, including social or environmental interventions.
The complexities of combined therapies should be discussed.

Teaching while on-call

Try to view teaching on call as an opportunity rather than an added burden. Viewing students only as workers during a call experience can have long-lasting repercussions: when students feel overworked without getting anything in return, they will view that specialty negatively. Conversely, students are often willing to work hard as long as they get some teaching in return. Even one to five minutes of active teaching during a hectic call will be appreciated.
Learn to see all teaching opportunities as important.
In many programs, students are assigned to be on call with residents other than those with whom they are primarily working. Even if a resident works with a student only once, this can be a golden opportunity to influence developing knowledge of and attitudes towards psychiatry. Be aware of "teachable moments." Take advantage of down-time on call when it happens. Also, think creatively about ways to teach even the call is busy and stressfull. A few ideas are listed below:

         o Meet briefly with an inpatient to teach about a specific form of psychopathology.
          o Allow the student to conduct an observed interview in the emergency room and discuss it afterwards.
          o Thoroughly discuss patients seen emergently or in consultation.
          o Give an informal lecture on a topic of interest.
          o Look up something together that you both have a question about.

TEACHING PRINCIPLES � WHAT WORKS

Most of us can remember one or more outstanding teachers we admired, whether in elementary school or residency. Take a few minutes to reflect on (and even write down) some of the qualities and techniques your best teachers employed. What did they do to promote your desire to learn? How did they treat you? What especially effective strategies did they use? Teaching workshops often use this technique (brainstorming about what makes a good teacher). Also, thinking about ineffective teachers can help clarify what doesn�t work.

Research on clinical teaching has identified a number of behaviors and qualities shared by exemplary teachers (Irby, 1994; Kernan et al., 2000):

Actively involve students, asking many questions
Use the Socratic teaching method (although caution is warranted � this kind of questioning should not become an exercise in "What am I thinking?"). Challenge students to reason with clinical information and explain their choices
Students need to have the opportunity to assimilate pertinent clinical information, arrive at a differential diagnosis, and explore alternative possibilities. Capture attention and have fun.
Teachers who make the material come alive help students remember cases and teaching points. Specific ideas include role-playing (a resident can play the part of a patient with a particular symptom, complaint, or mental status finding) or playing games (e.g., some services use a "Jeopardy"-like format to ask students and more junior residents about specific topics). Connect the case to broader concepts
Help students generalize from a case or problem. For example, if a patient presents with suicidal ideation, discuss the epidemiology of and risk factors for suicide, discuss ways of asking about suicidal thoughts and intent, and/or broaden the topic to discuss the relationship between depressive symptomatology, severity, and suicide. Teach by modeling patient interactions
Demonstrate interviewing techniques for students and observe students� interviews and physical examinations. Meet individual learners� needs
Ask students "What would you like to learn on this rotation?" and "What kinds of issues or topics in psychiatry specifically interest you?" and address these. Be aware that different people have different learning styles. Support learners� autonomy and show respect
Supporting autonomy means working from the students' perspectives to promote their active engagement. Be practical, relevant, selective, and realistic
Think about what students (most of whom will not become psychiatrists) really need to take away from their psychiatry clerkship. It is usually wise to avoid bombarding students with esoteric bits of knowledge. Have students research specific issues related to interesting cases they are involved in. Use gaps in team members� knowledge as opportunities for medical students to do a literature search and present a five- to ten-minute talk. Provide feedback and evaluation
This is an obvious, but often inadequately realized, aspect of teaching (addressed in more detail below). In general, students benefit from prompt, specific, and direct feedback.

A five-step approach to effective teaching

A useful model for clinical teaching was developed by experts in medical education (Neher et al., 1992). It consists of five steps that residents can practice in any teaching encounter:

Step 1: Get a commitment from the student.

Ask the student for his or her interpretation of the case or data. Consider this as a way to "diagnose" the learner�s needs, enabling you as a teacher to meet the student where he/she is and adjust the level of your questions and teaching accordingly. Examples of questions to ask include:

    * What do you think is going on with this patient?
    * What are the biggest priorities to address with this patient?

Step 2: Probe for supporting evidence.

This allows further refinement of your appraisal of how the learner is approaching clinical problems or material. Without asking such questions, you may not discover gaps in knowledge. Questions useful in this include:

    * What leads you to think that?
    * How did you come up with that diagnosis/plan/treatment, etc.?
    * What is your differential diagnosis?

Step 3: Encourage discussion.

Promote more complex thinking and better learning by the following questions:

    * How reliable was the information the patient gave you?
    * How do your feelings affect what happens next with this patient?
    * How was it for you talking with this patient?
    * What are your ideas about a treatment plan?

Step 4: Reinforce what was right.

Always praise the learner for SPECIFIC actions and responses, making sure to comment on the results of their actions. Positive comments about students� initiative and presentations are always appreciated as well.

    * Specifically, you did a good job of�because�
    * I really liked when you said�because�

Step 5: Correct a mistake/teach a general rule

If the learner has performed satisfactorily, take the opportunity to provide them with a "pearl." If there are mistakes to be corrected, choose ONE and focus on it. Often, you can gently correct mistakes by teaching a general rule.

    * When I see a patient (who makes me feel) like this, the first thing I do is�
    * Next time this happens, you might try�

GIVING FEEDBACK & EVALUATING STUDENTS

General principles regarding feedback

Effective feedback is a function of 1) the student�s level of awareness about what is being reflected; 2) the student�s perception of impartiality of observations; and 3) rapport.
Effective teachers strive for an awareness of how their own cognitive or emotional biases may color the feedback they provide. Learner-centered strategies emphasize the importance of the student�s perspective and expectations and are particularly effective (Sachdeva, 1996). Feedback from a resident who consistently has the student�s best interest in mind will be perceived as trustworthy and meaningful.

Specific tips for providing feedback

Be fair. Share positive feedback before negative. While it can be challenging to incorporate this element, the ability to identify assets and redeeming qualities in another person is a valuable skill for teaching and psychotherapy.
Be specific. A specific comment such as, "When you reflected back for the patient the shame you thought she might have felt, she obviously appreciated your comment and elaborated on her experience," will be more effective than the more general, "You were very sensitive to her feelings."
Be consistent. For example, if a student is always disorganized in presentations, address this each time; don�t let several instances go unnoticed such that she incorrectly thinks she has improved.
Be timely. Experienced teachers pay attention to "teachable moments." In other words, clinical teaching can happen almost anytime, anywhere. Keep feedback appropriate to the context in which issues arise. Also, formal feedback should be given at the midpoint and end of a clerkship, so students know how they�re doing and can work on improvement.
Be flexible Recognize that there are multiple ways of approaching a clinical issue or accomplishing a task.
Be open Consider individual differences that may affect the student-resident dyad, e.g., gender, culture, and race/ethnicity.
Be collaborative. Ask the student for his or her view of the target issue. In this, it may be preferable to first ask for an overall impression performance, e.g., "So, how do feel you�re doing so far?" Use a tone that conveys encouragement and optimism. Help the student identify problems and arrive at a joint agreement on solutions for the future.

Areas for comment on student evaluations

    * Attendance
    * Attitude toward clerkship
    * Evidence of collateral reading
    * Assessment of knowledge base
    * Thoroughness and accuracy of assessments
    * Interpersonal manner with patients, families, staff, peers, residents, and attendings
    * Professionalism (acting with integrity, respect, and compassion)

UNIQUE ISSUES FOR PSYCHIATRIC RESIDENTS AS TEACHERS

Stigma against psychiatry and its practitioners

Despite advances in de-stigmatizing mental illness, significant misunderstandings and prejudices still exist. Medical students often enter their psychiatry rotation with a poor understanding of what psychiatric patients are like and what psychiatrists actually do. In teaching students, you have the opportunity to:

Openly discuss the stigma against mental illness with medical students
Allow students to explore their feelings and ideas about psychiatric patients. Emphasize how the stigma against psychiatric patients can contribute to their receiving decreased quality of care. Help students develop empathy for psychiatric patients
Identify and discuss ways in which mental illness has significantly affected patients� lives. Attempt to "de-bunk" myths about mental illness
Common misconceptions include: "Psychiatric patients never get better," "patients with mental illness are often unpredictable and dangerous," and "mental illnesses are less �real� than medical illnesses." In addressing these, consider the following factoids:
According to the 1999 Surgeon General�s Report on Mental Health (SGRMH), about 20% of the US population is affected by mental disorders at any given time.
Seven of the top ten causes of disability in industrialized nations are mental disorders, with depression and alcohol abuse causing more years lost to disability than the next five combined (Murray and Lopez 1996).
In a study from the National Institute of Mental Health (1993), success rates (defined as a substantial reduction or remission of symptoms) in treating mental illness were better than some medical procedures: schizophrenia 60%, depression 60-65%, panic disorder 80% vs. angioplasty 40%, atherectomy 50%.
Success rates in addictive disorders are similar to other chronic illnesses: alcoholism 50%, opioid dependence 60%, cocaine dependence 55% (O�Brien and McLellan 1996).
The rates of compliance in psychiatric disorders are similar to those in most other chronic diseases. E.g., less than 60% of adults with type I diabetes mellitus, and less than 40% with hypertension and asthma, fully adhere to their medications (Ewing et al 1999).

Teach strategies for interacting with a range of psychiatric patients
For example, discuss ways of setting boundaries with a patient with Borderline Personality Disorder. Discuss students� views of psychiatry, especially any preconceived notions of what psychiatrists do
Be a role model of a good physician as well as a good psychiatrist
Be caring, kind, and respectful to patients, medical students, staff, and other physicians. Teach practical skills that will benefit students regardless of career path
Recognize that most students will not go into psychiatry. Teach students how to treat the most common psychiatric disorders and when to refer to a psychiatrist. Teach how to evaluate patients for competency and how to manage agitation and delirium. Talk about electroconvulsive therapy (perhaps our most misunderstood treatment)
ECT has proven efficacy in treating many severe forms of mental illness, especially psychotic depression. It may be helpful for medical students to see ECT and talk with patients before and after their treatments.

Methods of psychiatric examination, diagnosis, and treatment often appear unique and different from other fields of medicine.

Teach students how to conduct a good mental status exam and emphasize the role this plays in psychiatric diagnosis.
Discuss the strengths and limitations of the DSM-IV as a tool for psychiatric diagnosis. For example, the DSM provides good inter-rater reliability and good correlation with treatment efficacy, but the criteria are still fairly subjective and the diagnoses are often not grounded in objective findings (such as lab tests, imaging, or tissue pathology).
Teach the multi-axial system and how it provides a more holistic method for diagnosing patients
Ideally, this system allows the psychiatrist to establish a global assessment of functioning by placing the patient�s current illness in a context of personality structure, medical co-morbidities, and psycho-social stressors. Discuss the importance of the relationship between doctor and patient as a component of psychiatric diagnosis and treatment
Emphasize the multi-modal treatments often used in psychiatry
These include medication management, forms of psychotherapy (including CBT, DBT, psychodynamic psychotherapy, group therapy), case management/social work, and use of community resources (such as detoxification centers, addiction treatment centers, AA/NA, shelters, and support groups).

Residents may feel the need to teach subject matter or skills they have yet to learn for themselves.

Psychiatry training programs are often designed such that residents spend the first 1-2 years of residency working on inpatient psychiatric units or in other acute care settings; these are also the services on which most medical students rotate. As a result, medical students are often taught by residents who haven�t had extensive exposure to other important aspects of the field, such as psychotherapy, addictions treatment, child and adolescent psychiatry, and community psychiatry. Given this, residents should consider the following as they teach:

Only teach what you know
For what you don�t know, teach students how you learn about new aspects of the field. Allow students to learn about a topic and teach you
Encourage students to interact with more senior residents and attendings
This might include spending an afternoon each week in an outpatient clinic or on a specialized consult service (such as addictions or geriatric psychiatry). Enlist the help of others (chemical dependency counselors, case managers, social workers, nurses) in teaching students
Psychiatry is often best practiced as a multi-disciplinary team; this also provides a model for how to teach it.

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