The field of psychoanalysis and psychodynamic psychiatry correctly perceives itself to be increasingly marginal in American medical education. This does not mean, however, that the marginalization is good for American medical education; nor does it mean that faculty trained in these areas are not needed and wanted. The time may be right for a reconciliation that would benefit psychoanalysis, psychodynamic psychiatry, and American medical education.
CHANGING ECONOMICS OF MEDICAL EDUCATION
The past 10 years have seen tidal changes in the logistical base of American medical education. With the training of more researchers, scientists are increasingly competitive with each other and medical schools are more competitive with each other for research dollars. Although increases in the research budgets of NIH and NIMH are expected for the near future, tight competition for research dollars will remain. The falling reimbursement rates from managed care and Medicare mean that clinical and education income is under substantial strain. The medical schools therefore have suffered a one-two punch at the economic base of their enterprise. This means that full-time faculty in research or clinical work are spending more and more of their academic time on research or clinical work that is directly economically productive. They are hard pressed for time to teach.
At the same time, medical education has shifted dramatically in its task and its curricular content. It has had to incorporate an increasingly diverse set of topics while integrating basic science teachings and expanding the breadth of clinical education experiences. It has become more focused on understanding the major sources of morbidity and mortality and targeting those sources, either in illness-specific ways (hypertension) or in clusters of related high-morbidity illness groups (cardiovascular disease). One of the most frequent of these clusters is depression, because this psychiatric illness is a major public health issue. In all of these illness categories, more attention is being given to chronic care and primary, secondary, and tertiary prevention—and that means helping patients with lifestyle and behavior changes.
In addition, the growth of general medicine as a subspecialty, an increase in public awareness about doctors, and the public health need for patient cooperation and compliance in medical care have brought the psychological factors in the doctor-patient relationship back into central focus in medical education. We teach the doctor-patient relationship and medical interviewing. These courses are supplemented by courses in the ethics and values of a patient-centered humanistic medical care.
In order to teach these subjects well and to give the students the practical ability to use the information and to build necessary interpersonal skills, medical schools have changed teaching methods to emphasize more small-group teaching and one-to-one clinical mentoring. Such teaching requires a smaller student-faculty teaching ratio than does lecturing or ward rounds.
We thus see the entire logistical base of medical education shifting in terms of income, available faculty time, and need for teachers. This means that medical schools are crying out for donated, voluntary faculty teaching time. Particularly needed are voluntary faculty who have skills in the psychological aspects of medical care and can teach doctor-patient relationships and the potential for behavior changes based on those relationships in the practice of long-term care. The need for teaching of this kind provides the potential entree for the psychodynamic psychiatrist and psychoanalyst. Those of us with this training are uniquely poised to become the mentors and general medical educators of the twenty-first century. Psychoanalysts and psychodynamic psychiatrists could fill the role of psychodynamic experts on the doctor- patient relationship, life-cycle development, and the clinical process teaching that the new medical pedagogy is embracing.
BARRIERS WITHIN PSYCHOANALYSIS TO THE NEW MEDICAL PEDAGOGY
In order to join the new medical pedagogy, however, psychoanalysts and psychodynamic psychiatrists must understand the changes in the goals and venues of medical teaching that have been based on the changes in economics of medical education. Psychoanalysts and psychodynamic psychiatrists must understand that the teaching opportunities are enormous but that they are unremunerated. Faculty must be willing to donate a part of their time. Psychoanalysts and psychodynamic psychiatrists must also understand that the need is for psychodynamics applicable to medical care and not for pure psychoanalysis and its metapsychology. Medical students need to know about feelings and emotional adaptations, not about the development of the libido. They need to know about normal development and not just about pathology and neurosogenesis. Psychoanalysts must therefore be prepared to teach clinical process and not just psychoanalytic process, clinical values and not just psychoanalytic values. Psychoanalysts and psychodynamic teachers must join their general medical colleagues in teaching warm therapeutic relationships with patients rather than psychoanalytic blank-screen relationships. All the subtleties of transference and countertransference can still be seen and understood in this more relational context because the transference reactions are great in the medically ill.
Because of the research mission of medical schools, the modern medical school psychoanalytic teacher will have to teach analysis in relationship to biology and not in opposition to biology. Nothing will peripheralize the profession more than to ignore the dramatic leap forward in understanding brain function and psychiatric illnesses that the Decade of the Brain has brought us. With modern neuroimaging, genetics, immunology, and informatics, one can anticipate more rapid progress in the new century. Psychoanalysts as clinicians have much to teach about sophisticated clinical phenomena that cry out for sophisticated research. But in order to expand the research mission, they must embrace research, not oppose it.
PAYOFFS
The payoff to medical education of increasing involvement by analysts and psychodynamic psychiatrists is an increase within medical education in understanding the patient-centered skills and values that are required for clinical excellence. It will mean a richer and deeper education for students as they enter the psychologically complex realm of clinical care. It will mean increasing opportunities for sophisticated teaching and for the kind of faculty development that inspires teachers and drives teaching programs. It will offer the opportunity for sophisticated clinical research on these relationship issues and their impact on medical care.
As medicine shifts more and more to the treatment of chronic illness and as these chronic illnesses more and more require chronic medication and lifestyle changes, the issue of cooperation by patients with these regimens comes to the forefront of medical concern. These issues are psychological issues. Little is known about how to bring about dramatic lifestyle changes required for the control of atherosclerosis, hypertension, and diabetes, to mention three of the most frequently morbid chronic illnesses. We know for sure that scaring people and providing them merely with facts doesn't work. Because these issues often involve different specialties, the potential for interdisciplinary teaching, patient care, and research is very great and is probably the challenge and the opportunity of the next century.
The payoff to psychoanalysis can be in the increasing medical respect and interest with which medical students and residents regard psychoanalysis. This may pay off in increasing numbers of candidates and of patient referrals as the relevance of psychoanalysis is seen. An additional, badly needed payoff to psychoanalysis can come in integrating modern medical research methodology with the understanding of clinical work within psychoanalysis. Initial, broad-based outcome studies are actually quite positive for psychodynamic treatments. Many studies have shown that the more intensive the therapy and the longer it continues, the better the results. What is lacking is research sophisticated enough to provide an understanding of specificity about psychoanalysis and psychodynamic psychotherapy as a method and its specific application to specific illnesses. Medical schools may have research methodologies that can help.
CONCLUSION
If psychoanalysts do not fill this medical education vacuum, it will soon be filled by others. A multitude of cognitive and behavioral approaches exist and a large number of practitioners are available to teach them. But analysts and psychodynamic psychiatrists should remember that we all have one primary goal: the best of patient care accompanied by the best in medical education.