Medical Students Judgments of Mind and Brain in the Etiology and Treatment of Psychiatric Disorders. A Pilot Study

Transcription

1 Medical Students Judgments of Mind and Brain in the Etiology and Treatment of Psychiatric Disorders A Pilot Study Michael A. Brog, M.D. Karen A. Guskin, Ph.D. Given the importance of how medical students conceptualize psychiatric illness along the biological psychological spectrum, it is surprising that little has been written about this phenomenon or about the factors that contribute to it. The authors designed a questionnaire to assess how medical students view mind and brain issues in psychiatry as they relate to the treatment and etiology of psychiatric disorders. Seventy-nine thirdyear medical students completed the questionnaire midway through their 8-week clerkship. Results indicated that third-year medical students weigh both psychological and biological factors in a balanced way when considering the etiology and treatment of psychiatric disorders. (Academic Psychiatry 1998; 22: ) The trend in psychiatry toward placing an ever-increasing emphasis on biological over psychological phenomena has become a growing cause for concern among some academic psychiatrists (1,2). The focus of this concern has remained primarily on how this trend impacts psychiatrists and psychiatric residents in their conceptualizations of psychiatric illness and its treatment. Related to this issue, but little studied, is the question of how medical students conceptualize psychiatric illness on the mind brain continuum. This question has become of increasing relevance from two perspectives. From an academic perspective, it is an oft-stated goal that we help medical students appreciate the complexity of psychiatric illness in all of its biopsychosocial determinedness. Slavney (3) has called the mind brain problem the fundamental mystery in our field and has noted that the problem of attributing psychopathology to psychological vs. neurophysiological events is often without definitive solutions, and that this has contributed to attempts by psychiatric educators to ignore the dilemma or to finesse it in various ways. Perhaps one manifestation of these attempts is the increased emphasis on neurobiological issues over psychological and psychodynamic issues in the psychiatric education of medical students (4). Attending to psychotherapy concepts during clerkship experiences has been said to be disadvantageous because it differs from the more clear-cut medical model of pathology that medical students are presented with in other clerkships, a Dr. Brog is Assistant Clinical Professor. Dr. Guskin is Assistant Professor. Both are in the Department of Psychiatry, Saint Louis University School of Medicine, Missouri. Address reprint requests to Dr. Guskin, Department of Psychiatry, David P. Wohl Sr. Memorial Institute, 1221 S. Grand Blvd., Saint Louis University School of Medicine, St. Louis, MO Copyright 1998 Academic Psychiatry. ACADEMIC PSYCHIATRY 229

2 ETIOLOGY AND TREATMENT OF PSYCHIATRIC DISORDERS model with which they are assumed to be more comfortable (5). Some have suggested that medical student exposure to patients who show clear-cut responses to medication provides a more enjoyable experience for medical students during their short psychiatry rotation (5). Others have emphasized the importance of balancing biological and psychodynamic perspectives, with a view toward helping medical students see psychiatry as the great integrator of biology and psychology (6). However, medical students openness to such integration is unclear given the biological vs. psychodynamic turf battles that psychiatrists themselves continue to wage. Knowing more about how medical students conceptualize mind brain issues also has relevance for the future of how psychiatry is practiced. Recent health care changes, including the increasing emphasis on managed care, have intensified the pressure on psychiatrists to become brain - oriented psychopharmacologists, leaving the psychosocial interventions of the mind to other nonmedical clinicians. The opinions of nonpsychiatric physicians about the role of psychiatry in health care can be identified as one outside force that affects the way in which psychiatry is practiced. The understandings about psychiatric illness that medical students carry with them into their careers influence health care trends and referral patterns, which are already increasingly out of psychiatrists control. Given the importance of how medical students conceptualize psychiatric illness along the biological psychological spectrum, it is surprising that little has been written about this phenomenon or about the factors that contribute to it. The specific aims of the current pilot study are 1) to provide descriptive data on the mind and brain attitudes of third-year medical students toward psychiatric diagnoses and treatment and 2) to examine whether there are individual differences in responses based on gender, rotation experience, and specialty preference. Our initial hypothesis was that medical students would tend to emphasize biological over psychological interventions and etiological factors in their conceptualization of psychiatric disorders over all diagnostic categories. Given previous research on medical student attitudes toward psychiatry (6), we thought this might be especially true for students in the following groups: those who rotated through more medical model sites (Veterans Affairs and geriatric), males, and those with nonprimary care/psychiatric specialty interests. We also predicted that third-year medical students would not as a group discriminate in their considerations of etiological factors and treatment between those diagnostic entities that are recognized as having an especially strong biological diathesis (schizophrenia, bipolar affective disorder) and those in which psychological factors would generally be considered to play an important role (major depression, panic disorder, borderline personality disorder). To look at these questions, we designed a questionnaire to measure how medical students view mind and brain issues in psychiatry as they relate to the treatment and etiology of psychiatric disorders. METHODS Participants Between July 1, 1993, and June 30, 1994, 79 third-year medical students completed the questionnaire (response rate: 52.7%). Seventy subjects (88.6%) were years old and 9 (11.4%) were years old. Of the 75 who reported their gender, 57 were male (76.0%) and 18 were female (24.0%). These numbers mirror the actual gender distribution of the students in the class: of the 150 students who were enrolled in the clerkship during the year, 110 (73.3%) were male and 40 (26.7%) were female. Not surprisingly, the v 2 goodness-of- 230 VOLUME 22 NUMBER 4 WINTER 1998

3 BROG AND GUSKIN fit test was nonsignificant (v , df 1, NS). Of the 91% of the respondents who expressed an interest in only one specialty area, the most popular specialty choices were surgery (23.6%), pediatrics/pediatrics subspecialty (19.4%), internal medicine/internal medicine subspecialty (16.7%), and family practice (15.3%). To also examine the representativeness of our respondents, we compared their specialty choices to the specialty choices of the 90 students from our medical school who completed the American Association of Medical Colleges 1995 Graduation Questionnaire and who expressed interest in only one specialty. The v 2 goodness-of-fit test was nonsignificant (v , df 4, NS), indicating that our respondents did not differ from the latter group in their anticipated choice of specialties. Materials The questionnaire is composed of questions about background information on specific subjects and two sections examining respondents beliefs about effective therapeutic strategies and the etiology of psychiatric disorders (a brief final section that asked questions about psychiatrists role and identity is not included here). Background information consisted of subject age, gender, rotation site completed, and medical specialty preference. (The questionnaire is available from the first author.) The Therapeutic Strategies Scale consists of a list of 12 different Axis I and Axis II diagnoses, including psychotic, affective, anxiety, eating, and personality disorders. The diagnoses were selected to represent those disorders that students would be most likely to encounter during their clerkship. Subjects rate on a 5-point scale the type of therapeutic philosophy they would most likely use in ongoing outpatient psychiatric treatment of a 30-year-old patient not currently needing hospitalization. A 1 on the scale represents the response primarily psychopharmacology, a 3 represents an equal emphasis on psychopharmacology and psychotherapy, a 5 represents primarily psychotherapy, and the other points on the scale reflect intermediate responses. The Etiology Scale consists of the same 12 diagnoses, but subjects are asked to rate on a 5-point scale the degree to which each of the following contributes to the development of the disorder: genetically inherited predisposition, early childhood experiences, neurotransmitter abnormalities, and unconscious conflict. A 1 on the scale reflects the response no contribution, whereas a 5 represents the response invariably a crucial causal factor in the disorder. Two of these etiological factors (neurotransmitter abnormalities, genetic predisposition) are of a more biological nature, whereas two of them (unconscious conflict, early childhood experiences) are of a more psychological nature. Procedure The questionnaires were distributed in class at the end of the fourth week of the 8- week clerkship, and students were given minutes to complete them. Because the students switch rotation sites after 4 weeks of the clerkship, the midway point was chosen to enable the results to be analyzed based on students different rotation experiences. The cover letter attached to the questionnaire stated that student participation was purely voluntary and that all responses would remain anonymous. Anonymity was used to ensure that students did not feel that their responses were being used as a part of their clerkship grade. There was no follow-up or additional recruitment of subjects because of the anonymity of responses and based on the concerns of the clerkship instructor and the ACADEMIC PSYCHIATRY 231

4 ETIOLOGY AND TREATMENT OF PSYCHIATRIC DISORDERS Institutional Review Board that students not be pressured into responding. TABLE 1. Analyses Mean scores and standard deviations (SDs) were computed for each diagnosis for both the Therapeutic Strategies and the Etiology Scales. In addition, mean SD scores for each of the etiologies were computed. Correlational analyses were computed by using Pearson correlation coefficients. Multivariate analyses of variance were used to examine the relationships between participants background characteristics and scores on the questionnaire. RESULTS Beliefs About Effective Therapeutic Strategies for Psychiatric Disorders As can be seen from the results presented in Table 1, the medical students were able to take into account the type of diagnosis when judging what therapeutic strategy would be most helpful. Mean scores for the diagnoses ranged from 1.94 to 4.29, indicating both a sensitivity to diagnosis and an understanding of the benefits of both Effective therapeutic strategies ranked by diagnosis, from most biological to most psychological Diagnosis Bipolar affective disorder, manic phase Schizophrenia, paranoid type Generalized anxiety disorder Major depression, mild Panic disorder Obsessive-compulsive disorder Posttraumatic stress disorder Adjustment disorder with mixed emotional features Conversion disorder Borderline personality disorder Bulimia nervosa Narcissistic personality disorder Mean SD pharmacological and psychological interventions. In addition, contrary to our expectations, the mean score across all diagnoses was 3.29, with the means for 8 of the 12 diagnoses above the midpoint of 3.0, thus suggesting that medical students believe, on average, in the efficacy of psychological interventions over pharmacological interventions. The two diagnoses with the lowest scores, bipolar affective disorder manic phase and paranoid schizophrenia, accurately parallel diagnoses that experienced psychiatrists would also point to as having especially strong biological diatheses. Beliefs About the Etiology of Psychiatric Disorders Mean ratings for each of the four possible etiologies (neurotransmitter abnormalities, genetically inherited predisposition, early childhood experiences, unconscious conflict) were computed, as were mean scores for each diagnosis, across etiologies. On average, across diagnoses, the medical students ranked early childhood experiences and unconscious conflict as more important than genetically inherited predispositions and neurotransmitter abnormalities in the etiology of the 12 psychiatric disorders (see Table 2). Ratings of the influence of early childhood experiences and unconscious conflict were significantly correlated (r(79) 0.33, P.001), as were the ratings of genetically inherited predispositions and neurotransmitter abnormalities (r(79) 0.48, P 0.001); all other intercorrelations between the four etiologies were nonsignificant (P 0.10). To compute the mean etiology score for each diagnosis, the scores for genetically inherited predisposition and neurotransmitter abnormalities were reversed and averaged with the scores for early childhood experiences and unconscious conflict. A higher etiology score thus reflects a less biological and more psychological approach. 232 VOLUME 22 NUMBER 4 WINTER 1998

5 BROG AND GUSKIN As can be seen in Table 2, the results indicate that the students were also sensitive to the type of diagnosis, with average scores ranging from 2.38 to 3.83, and 9 of 12 diagnoses being rated as having more psychological than biological origins. Relationships Between Scale Scores and Medical Student Characteristics Etiology scores were positively correlated with therapeutic strategy scores (r(78) 0.23, P 0.05). We expected that medical student demographics and characteristics might lead to different attitudes toward the issues of mind vs. brain in psychiatry. Therefore, we analyzed the results from the Etiology and Therapeutic Strategies Scales by using separate multivariate analyses of variance for each of the following variables: 1) gender; 2) medical specialty interests; 3) time of year of the psychiatry clerkship (i.e., those students who have medicine and surgery experiences first, compared with those who have psychiatry, obstetrics/gynecology, and pediatrics first); and 4) rotation experiences within psychiatry. There were no significant differences on either the Therapeutic Strategies or Etiology Scale based on any of these factors (P 0.20). DISCUSSION The results of our questionnaire, counter to our expectations, strongly demonstrated the capacity of third-year medical students to weigh both psychological and biological factors in a balanced way when considering the etiology and treatment of psychiatric disorders. In their consideration of treatment options, these medical students showed that they recognized the importance of a combined approach of medications and psychotherapy for every diagnostic category. In their assessment of the TABLE 2. Diagnosis Ratings of etiology ranked by diagnosis, from most biological to most psychological Genetically Inherited Predisposition Early Childhood Experiences Mean SD Neurotransmitter Abnormalities Unconscious Conflict Overall Schizophrenia, paranoid type Bipolar affective disorder Major depression Generalized anxiety disorder Panic disorder Obsessive-compulsive disorder Borderline personality disorder Adjustment disorder with mixed emotional features Narcissistic personality disorder Conversion disorder Bulimia nervosa Posttraumatic stress disorder Overall ACADEMIC PSYCHIATRY 233

6 ETIOLOGY AND TREATMENT OF PSYCHIATRIC DISORDERS importance of these different approaches, they valued the role of psychotherapy to a surprising degree. In fact, they felt psychotherapy was of greater importance in more diagnostic categories than an intervention, the prescribing of medications, that fits far more comfortably within the standard medical model of illness to which they are accustomed. Similarly, in the students consideration of etiological factors in psychiatric disorders, factors that could be considered more psychological in nature were perceived by them to be of greater etiological importance in more categories overall, and in more Axis I categories in particular, than were factors of a more biological nature. This balanced approach was shown to be independent of gender, rotation site, medical specialty interest, and time of year when the rotation was being taken. Their responses established that medical students do not see all psychiatric disorders as lying at the same place along the biological psychological spectrum. They distinguished schizophrenia and bipolar affective disorder as being significantly more biological in nature, whereas narcissistic personality disorder, borderline personality disorder, bulimia, adjustment disorder, and conversion disorder were seen as being significantly more psychological in nature. The remaining categories, including major depression, panic disorder, and generalized anxiety disorder, were conceptualized as requiring a balanced approach in terms of understanding their causes and in their treatment. This ordering of diagnostic entities from biological to psychological corresponds well with the impressions of experienced psychiatrists. We find the importance given to psychological etiological factors, and to psychotherapy as a treatment modality, to be surprising. Even in those disorders recognized as being the most biological, the importance of psychotherapy and psychological factors was recognized as playing a meaningful, if less crucial, role. These findings were felt to be of particular significance given our observation that psychotherapy was of minor importance in, if not absent from, the activities of the students inpatient rotations, particularly for the majority of students at the Veterans Affairs and geriatric sites, and was not particularly emphasized in their lecture curriculum. Limitations of this study are the relatively low response rate and the restriction of the respondents to one medical school. Both of these factors limit the generalizability of the findings. Although our subjects did not differ from the nonrespondents on gender or specialty choice, it is possible that those students choosing to complete this voluntary questionnaire had an enhanced psychological mindedness compared with their peers and that the hypothesized preexisting biological prejudice among medical students was missed. Nonetheless, we believe the findings of this pilot study have implications for the training of medical students and the future of psychiatry as a specialty. Future studies could focus on students at other medical schools with differing curricula, comparisons before and after the clerkship experience, individual differences based on personal and educational experiences and past history, and comparisons with psychiatric residents and practicing psychiatrists. Factors such as these might indeed influence medical students attitudes toward mind and brain, despite the fact that our participants did not show differences based on the characteristics we analyzed. These results raise questions about current attitudes toward medical student education in psychiatry. Our results suggest that medical students recognize the importance of psychodynamics and psychotherapy and that they do not appear to devalue them as nonmedical or unscientific. We find these results to be encouraging and support the idea that medical students have both the 234 VOLUME 22 NUMBER 4 WINTER 1998

7 BROG AND GUSKIN capacity and the inclination to wrestle with mind brain issues in psychiatry and that medical students can have an appreciation for the importance of psychological factors, compared with biological considerations, when conceptualizing the etiology and treatment of mental illness. The authors thank John T. Chibnall, Ph.D., and Robin S. Park, M.D., for their assistance. References 1. Lewis B: Psychotherapy, neuroscience, and philosophy of the mind. Am J Psychother 1994; 48: Brenneis CB: The skewing of psychiatry. Academic Psychiatry 1994; 18: Slavney P: The mind brain problem, epistemology, and psychiatric education. Academic Psychiatry 1993; 17: Daniel DG, Clopton CL, Castelnuovo-Tedesco P: How much psychiatry are medical students really learning? A reappraisal after two decades. Academic Psychiatry 1990; 14: Lomax JW: Frequently asked questions about medical student education in psychiatry. Academic Psychiatry 1993; 17: Jurvetson KT: Characteristics of medical students and residents who select psychiatry. Academic Psychiatry 1995; 19: ACADEMIC PSYCHIATRY 235