Paging Dr. Freud--and his 21st century medical school reading list.

August 21, 2012 7:35 AM

Paging Dr. Freud--and his 21st century medical school reading list.

How much education in psychotherapy/psychoanalysis do medical school students who go on to specialize in psychiatry receive, especially in the days of split treatment (MD provides medication management/acute pharmacological care, PhD or LCSW provides psycho-social assessment and talk therapy)?

I'm not talking about special fellowships or programs focusing on psychotherapy for MD students--I'm asking about the generic, bare-bones starting point for medical students who go on to general psychiatry. Who and what are they reading these days?

posted by availablelight to health & fitness (10 answers total)

Scanning through the list of textbooks for the OSU Med 1 and Med 2 years (as far as I know everyone has to take every class) not a single textbook is even vaguely devoted to this topic. There's a "course packet" available for the Neurology section of Med 2, but that's it (I don't know how to find out what's in that packet without hunting down a current med student, but I'm pretty sure it's going to be about ten minutes on therapy, primarily in terms of how it totally changes your brain chemically.)

The Med 3 requirement in psychiatry lasts four weeks and is, from everything I've heard, based almost entirely around psychopharmacology and just kind of seeing what happens on the psych wards; it's not clear from the description (or from people I've talked to) what exactly Med 4 elective psychiatry elective students get up to (no one I know who went to med school did an elective psychiatry rotation, alas.) But I do know that they work out of the psychiatric hospital building (where all the inpatients are housed,) and no one I've ever talked to has suggested that even the residents, let alone actual doctors, at that hospital appear to know anything at all about therapy or even very much (visible to a patient) about abnormal psychology beyond "these symptoms match up with this diagnosis" and "these are the drugs that tend to work on this symptom" and maybe "why those drugs work that way." I think that anymore, if that's what they really wanted to do, they'd have gone for the MSW or whatever, and everyone (pre-med students, professors, current students, patients, etc.) knows this and behaves accordingly. It's been a long, long time since psychiatrists really did much therapy - at least, on the insurance/hospitals/managed care side of the world (which is what US med schools mostly have to cater to.)

So while I can't give a comprehensive answer, I'm going to go ahead and say "very, very, very little" for this medical school at least. It's likely that at the end of Med 2 they know most of what they know thanks to the fact that they decided to take psychology in order to do well on the newest version of the MCAT (psychology is merely "recommended" as a possible course in the social sciences, and is the last of several disciplines mentioned) or because they just flat-out wanted to.

It also seems pretty clear that there's a low expectation that a med school graduate applying to a psychiatric residency program actually have very much experience/specialization any kind of psychology-related subject - UCLA, for random instance, says that a mere recommendation from a professor in psychiatry isn't actually required.

And it looks like the overwhelming majority of applicants are matched to psychiatry if that's what they ranked first (it's on page 239,) so it seems the "market" (of residency programs) isn't signaling to the "producers" (med school curriculum writers) that anything is wrong with any of the above. Even the people with USMLE step 1/step 2 scores below 180 mostly got into psychiatry, as did most people with no work experience, most people with no volunteer experience, most people with no research published, most people regardless of how good their medical school is, etc. Psychiatry is clearly no kind of surgical discipline (they've all got much higher rejection rates, and check out the correspondingly huge requirements for anatomy and similar kinds of skills/knowledge in med school.)
posted by SMPA at 10:55 AM on August 21, 2012 [3 favorites]

Medical students receive pretty much zero formal education in how to do talk therapy. This probably varies a bit by school. A standard curriculum would likely be "therapy" listed as a treatment option when they learn about psychiatric disorders in the 1st and 2nd (preclinical) years, and then maybe getting to watch an actual practitioner a few times during the clinical years. Depending on the program, you might have one lecture devoted to different kinds of talk therapies. Students do get some training in motivational interviewing and things of that nature. It's generally not until a psychiatric residency that they get formal and lengthy training in therapy, which makes sense since it is a very specialized skill and takes far more time to develop than the 4-6 weeks most medical students spend on psychiatry in their clinical years.

I have no idea why SMPA is so focused on residency match rates, which correlate much better with post residency income and lifestyle factors than anything else. Yeah, psychiatrists don't make a lot of money. But no one gets formal teaching on how to do specialized surgical or dermatological procedures in med school either, for the very good reason that med school is about learning the basics and figuring out which specialty attracts you enough to devote the next few years to learning the complicated stuff in that specialty alone.
posted by The Elusive Architeuthis at 11:03 AM on August 21, 2012

PS-- at the hospital where I did my residency all the psych residents have the option of spending a couple of years undergoing traditional Freudian analysis and those that have the bent can train as analysts.
posted by The Elusive Architeuthis at 11:07 AM on August 21, 2012

How much education in psychotherapy/psychoanalysis do medical school students who go on to specialize in psychiatry receive

Very little. Of course, the same can be said about most practical treatment modalities for everything. A medical student will have performed, for example, zero surgeries by the time they finish their degree. They'll have done almost no procedures of any kind. Medical school is all about getting the foundational scientific and professional training you need before you can go on to learn about how to do stuff medically. When you graduate, you'll have a basic idea about what all the various specialties and disciplines do, but not how to do any of it.

That's what residency programs are for.
posted by valkyryn at 12:11 PM on August 21, 2012 [3 favorites]

That's what residency programs are for.

I should have been more clear (or more educated on the different stages of training): who/what's being taught, in terms of practice/theory, for residents in psych as well, who are not on special fellowships? Thanks so much for the answers so far.
posted by availablelight at 1:00 PM on August 21, 2012

I can only speak for Canada, but if you have a look at the national learning objectives for psychiatry residency programs (specifically, section 4), you'll see that residents are required to have proficiency in some areas of psychotherapy, working knowledge of some other areas, and introductory knowledge in further areas. From what I gather, speaking to a friend of mine who's a psychiatry resident, they do get training in psychodynamic therapy (the modern descendant of Freudian analysis), but the emphasis is perhaps a bit more on cognitive-behavioural therapy, and unless someone is already interested in doing more psychotherapy than pharmacotherapy, they'll usually not pursue any further training.
posted by greatgefilte at 3:16 PM on August 21, 2012

Who/what's being taught, in terms of practice/theory, for residents in psych as well, who are not on special fellowships?

Tanya Luhrmann wrote an entire book devoted to this topic, Of Two Minds: An Anthropologist Looks at American Psychiatry. I'd recommend reading through the introduction at least if you are interested in this topic. It's a fantastic book, which examines how various psychiatric residency programs balance the psychotherapeutic and pharmacological modes of treatment. All programs she looked at teach both, but their orientations with regard to the two approaches differed substantially.
posted by reren at 3:17 PM on August 21, 2012

Incidentally, I think most medical students (in Canada, at least) who don't end up in psychiatry will probably not know very much about psychotherapy other than CBT, simply because it gets the most advertising and probably has the best evidence behind it. Which is a shame, because there are certainly other forms of psychotherapy that are useful in specific circumstances, and even psychodynamic therapy as per Dr. Freud can certainly be helpful for the right person.
posted by greatgefilte at 3:23 PM on August 21, 2012

You might be interested in this, which is a brief "survival guide" for new residents hosted on the American Psychiatric Association webpage, which has a suggested reading list for all of the core competencies, including psychotherapy (page 24) as well as a couple of pages on "how to get the most out of your psychotherapy observation".

For US residencies, the ACGME, which is the body that accredits residency programs, specifies that a psychiatric residency program must include developing competence in

"applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and long-term individual practice, as well as to assuring exposure to family, couples, group and other individual evidence-based psychotherapies"

and

providing care and treatment for the chronically-mentally ill with appropriate psychopharmacologic, psychotherapeutic, and social rehabilitative interventions
posted by The Elusive Architeuthis at 6:26 PM on August 21, 2012

I am a psychiatrist, and I did a bunch of 4th year electives ("sub-internships") in psych (which turned out to be virtually a minority choice among my fellow residents). For each US state, in terms of non-"core clinical" rotations, there's a block of clinical hours that must be completed in order to graduate with an MD/DO, with a big skew towards ensuring a certain number of primary care hours, and some acute/urgent care with some in-patient medicine, But there's room to complete a fair bunch of electives. Few graduate programs insist that you complete specific electives in their specialty because, as pointed out above, your freedom to actually do anything intrusive, invasive or interesting is limited. Comparing what you can do in psych 3rd year with surgery, it's the mental equivalent of holding the retractor.

The purpose of 4th year of med school is mainly to audition for programs you are interested in, or to get more exposure to a specialty you might be interested in. Some programs like you to "branch out" before specialising (it's your last chance to dive into a bunch of crazy stuff!), and some will actually insist on doing some medicine such as critical care above and beyond core requirements because that sort of thing can make the intern year less of a steep learning curve.

But returning to your question, as pointed out above, the psych rotation in the 3rd year core clinicals is pretty basic and like all the core competencies, a typical med student can pass the standardised exams and much of the course just by working through a case files book and some multiple choice drills. For psych, because it's conceptually simple and operationally concrete, you get taught some CBT. There may be a few DBT sessions or similar depending on the program , but virtually none of this will be tested in the end-of-rotation exam and you could easily get by without reading a single psych didactic textbook. I'm just not sure there's anything more than a tiny minority reading Linehan, Gabbard, Cabaniss or similar, and in fact spending time reading those will probably reduce your performance in the standardized exams and the wards pimping.

You can get *exposure* to a bunch of therapy modalities in 4th year if you wish and, If you were interested and there was a specialty clinic, you could see how different therapy is used for, say, OCD versus PTSD. Or you can learn emergency psychiatry, which is the first triage step determining if a person can be best served as an outpatient, or requires acute hospitalization. But actually learning how do to therapy as a med student? Not really? As with so much of medicine, you can skim a bunch of theory, and gain didactic knowledge, but as the Luhrmann book referenced above points out, the whole point of the residencies as learning to be a doctor by doing a whole bunch of doctoring. There's a huge vocational aspect to it, along with experiencing how different health delivery systems function, how different specialties work together and communicate with each other (or not!), and basically becoming intuitively comfortable wearing this new skin.

You learn the different therapy modalities by doing them, by experiencing them in a room with many different patients (and as a medical student you lack the didactic framework and access to a sufficient number of patients). And as Luhrmann again illustrates, US psychiatric training requires both psychopharm and talk therapy proficiencies. Within the talk therapy proficiency, you can(and many people do) specialise along a specific region of the continuum between uncovering/psychodynamic and supportive/cognitive. The intent is to expose you to enough encounters that you begin assessing a patient during each encounter, you can move along that continuum as required by that encounter. For pure psychoanalytic work many residencies will have formal linkages with local institutes to provide both mentor supervision and suitable patients whereas some of the more "biological" residencies may not encourage something like that at all. If you think you will be interested in a specific modality or sphere of practice, then unless you want extra legwork it is beneficial to figure out in advance if a residency program you're looking at does have a specific skew along the analytic-biological spectrum. But again, like all the medical specialties, these are things where the fine details are often opaque to med students, and gaining proficiency in them can take many thousands of hours and years to get right and are often not amenable for anything other than surface observation by a medical student.

MD provides medication management/acute pharmacological care, PhD or LCSW provides psycho-social assessment and talk therapy

That's what a lot of patients see, and it's mainly an artifact of insurance reimbursements. Also, for the US at least, the difference between a psychiatrist who chooses to do mainly talk therapy and mainly medication management in a fee-for-service situation could easily be a 3x multiplier, as in, say, $150,000 for only-talkers, $450,000 for only-prescribers or docs focussed on addiction rehab or ECT and other neuromodulatory procedures. Many docs figure out a balance out between the two that satisfies them, but if you pay only through insurance reimbursements then there's a good chance all you're going to see that psych for is prescriptions. Even at a smaller community clinic/PES/ or hospital without its own psychiatrist service, where an LCSW is doing assessments to triage patients for acute hospitalization, at some point before that patient's admission/involuntary incarceration, that assessment will be reviewed by a psychiatrist (who may be at a remote 'tertiary' acute care psych hospital to where that patient may be transported).

The Elusive Architeuthis's assessment's of SMPA's rather snide focus is correct. The USMLE median, distribution and minimum scores for residencies are more a reflection of supply and demand than anything else. You're going to find extremely cerebral programs, such as internal medicine, with quite aggregate "relaxed" scores as a simple function of their vast ranks compared to some of less populous programs. What you will find in programs with an excess of supply over demand is a greater spread of scores - I know some psychs with USMLEs in the 180s, and others in the 250s and what's impressive is that they all tend to be quite reasonable physicians (mainly because of the gating aspect of med school entrance and the conforming curricula throughout the different schools). Finally, for many residency programs the demand factor can also be heavily influenced by location so national averages can be quite misleading for some larger cities.
posted by meehawl at 9:30 PM on August 21, 2012 [2 favorites]