Volume 1 Number 2
January 2006
Dear Colleagues,
Happy New Year ! We hope you enjoy reading updates and perspectives on medical student education in psychiatry in this second edition of the newsletter. Be sure to catch our new features: Profiles in Education and Student Faculty Forum.
A copy of this newsletter and other postings is located on our education website on eCommons (http://www.ecommons.harvard.edu/) which can be accessed by clicking on Links, OrgList, and then Medical Student Education in Psychiatry (MSE_Psych).
We welcome contributions from faculty and students including news items, reflections, cartoons, and photos. Please direct these contributions to our Editor-in-Chief, Heather Adams (heather_adams@hms.harvard.edu).
Best wishes for a great year !
HMS PSYCHIATRY FACULTY STUDENT RECEPTION
Sponsored by the HMS Student Interest Group in Psychiatry and the HMS Psychiatry Medical Education Council
MEC Atrium January 31st 5:15-7:15 PM
RESIDENCY TRAINING IN PSYCHIATRY INFORMATIONAL DINNER
An opportunity for all HMS students considering psychiatry residency training to meet with the Directors of HMS Psychiatry Residency Training Programs and Child and Adolescent Psychiatry Training Programs
Waterhouse Faculty Room, Gordon Hall March 29th 6-8 PM
MYSELL PSYCHIATRY RESEARCH DAY
Wednesday April 5th
12-1:30 Lunch for HMS Students/Residents with Tom Insel MD, Director of the NIMH
1:30-3 PM Poster Session
3:45-5 PM Mysell Awards and Plenary Lecture (Dr. Insel)
STEVE HYMAN
Informal Meeting of the Provost and former Director of the NIMH, Steve Hyman, MD, with the Student Interest Group in Psychiatry
Friday April 21st 5-6 PM
TMEC Walter Amphitheater
PSYCHIATRY SYMPOSIUM AND FACULTY DINNER
All HMS Psychiatry faculty invited.
Monday May 15th
Harvard Faculty Club (Cambridge)
Symposium and Dinner 3:30-8:30 PM
Keynote address: Jack Gorman, MD, President and Psychiatrist-in-Chief, McLean Hospital and Chair, Partners Psychiatry and Mental Health
For more information on any of these events, please contact Heather_Adams@hms.harvard.edu
Congratulations to the fourteen HMS students who were recently selected for the new Donald J. Cohen Fellowship in Child Psychiatry funded by a grant from the Klingenstein Third Generation Foundation. The prestigious fellowship program, which has been set up also at Yale, Johns Hopkins, Stanford, UC Davis and Mount Sinai Medical Schools, is designed to create and foster opportunities for mentored experiences in child and adolescent psychiatry.
HMS Student Fellows for 2005-2006 are: Deborah Doroshow, Adam Numis, Sona Chikarmane, Carlene MacMillan, Omar Haque, Rachel Lapidus, Jane Serene, Lauren Gold, Nanna Jumah, Michael Morse, Ashley Morris, Andrea Spencer, Gillian Fell, and Daniel Horton.
Faculty mentors for the program, which is directed by Steve Schlozman MD, include Sandra DeJong, Cindy Telingator, Nancy Rappaport, Larry Selter, Lisa Price, Jean Frazier, Katherine Grimes, Nina Muriel, Jeff Bostic, Laura Prager, Robert Ziegler, Anna Abrams, and Stuart Goldman.
A first annual "Havard @ Yale Event" will be held on Saturday February 11th bringing together Donald J. Cohen Fellows from New Haven and Boston. HMS speakers at the event will include Jonathan Alpert MD PhD who will describe Donald Cohen's contributions to child psychiatry and medical student education, Steve Schlozman MD who will discuss Child Psychiatry and the Media, Hope Levin MD who will delve into the character of Napolean Dynamite: Asperger Syndrome or Sad Misfit ?, and Andrea Spencer HMS2 who will share insights from international child mental health research.
On November 14th, about 50 HMS students and residents from HMS Psychiatry Residency Training Programs shared a Thai food dinner in the MEC Atrium followed by remarks from the Student Interest Group Co-Leaders, Deborah Doroshow and Adam Numis, and comments on psychiatry training by residents from the Cambridge Health Alliance Child and Adolescent Residency Training Program (Chike Nwanko MD), Harvard Longwood Adult Psychiatry Residency Training Program (Ethel Bullitt MD and Andrew Michael MD), MGH/McLean Adult Psychiatry Residency Training Program (Lucy Epstein MD, Mireya Nadal-Vicens MD), and South Shore Residency Training Program (Abode Hamoush MD and Nina Graupera MD). Commitment to medical student education is strong among HMS Psychiatry Residents and a Resident Advisory Council on Medical Student Education in Psychiatry is planned for this spring.
Steve Schlozman MD, Associate Director of Medical Student Education in Psychiatry and Course Director of the Introduction to Psychopathology course (700MJ), was recently selected as a recipient of the Fifteenth Annual Nancy C.A. Roeske, M.D., Certificate of Recognition for Excellence in Medical Student Education. This national recognition from the American Psychiatric Association highlights outstanding and sustaining contributions to psychiatric education for medical students. The Certificate will be awarded at a luncheon for medical students, residents and educators at the 2006 APA Annual Meeting in May which will be held in Toronto.
Dr. Mary Anne Badaracco, Chief of Psychiatry at the BIDMC and MMHC and Chair of the HMS Psychiatry Medical Education Council, was the recipient of the 2005 Nancy C.A. Roeske M.D., Certificate of Recognition for her remarkable contributions to medical student education and psychiatry education reform at HMS.
Catastrophic Illness, Human Suffering, and Psychopathology: How to Help, Where to Start
SUSANNA B. MIERAU, HMS III (Cannon Society), Co-Leader, HMS Student Interest Group in Psychiatry 2004-2005 writes...
I was two months into my surgery rotation when I met Mrs. H. She was a pleasant, well-organized, and thoughtful woman in her early 60’s who had a recent cancer diagnosis with a dismal five-year survival rate. Although she had anxiety about the future and a history of clinical depression, she also had strong social support. I met many of her friends during my visits with her. As I heard their stories, I learned that although they were here to support her now, in the past it was she who had always been a huge support to them.
After the 10-hour surgery to remove Mrs. H’s tumor, she was transferred to the ICU. Although her vital signs improved quickly and she was moved to the floor, the post-operative Mrs. H. was transformed from the woman I had met the week before. She was alert and oriented to name and place; however, she no longer engaged the speaker. Her cry of “help me” could be heard from across the pod, and during the night, she pulled out all of her tubes including her feeding tube, which could not be replaced. This led to a cycle of haldol and restraints to prevent her from further impeding her recovery. The day I left the service, her restraints had come off, but she was still forlorn and unengaged.
Today, I still find several aspects of my experience caring for Mrs. H disturbing. First, it was alarming to see the abrupt decline in her functioning after the surgery. The “adjustment disorder” diagnosed by the psychiatry consult seemed to understate the change I saw in her. Second, I was dissatisfied with our team’s ability to help her with the non-surgical aspects of her care. The restraints prevented further physical damage to herself, but did not address the underlying change in her psychosocial state. The consensus on the team was that if there were an available route to administer antidepressants, her condition would improve. Although this would have treated her chronic depression, this approach seemed unlikely to relieve the reactive depression she may have been experiencing due to her oncologic illness.
Lastly, it was difficult for me to separate what part of her behavior post-surgery was an appropriate response to her situation and what was pathologic. Although her depressed mood and line pulling was attributed to depression, she had many reasons to grieve. She underwent an enormous surgery. She was still coming to terms with a devastating cancer diagnosis. She had a nasogastric tube and was allowed no food or water leaving her mouth dry and voice hoarse. Could I attribute her pulling out her feeding tube in the night to a moment of despair that anyone might feel in a similar situation? I am left to ponder which behaviors might be justified as a rational response while I seek to observe how other patients respond to similar situations. I would also like to explore what can be done acutely in the hospital setting to support people experiencing great and irreversible loss while preventing behaviors that can impair their recovery.
SUSAN D. BLOCK, MD responds...
Dr. Block is Chief of the Division of Psychosocial Oncology and Palliative Care at the DFCI and BWH and Co-Director of the HMS Center for Palliative Care. She is also Associate Professor of Psychiatry at HMS.
The patient described in this case was catapulted by her diagnosis and surgical treatment into a state of profound distress. Because she was so ill, much of her subjective experience is not accessible to us. It is clear that she was suffering profoundly. We don’t know what she was feeling or thinking, beyond her request to “help me.” It is easy to imagine many factors that may have contributed to her distress – terror, helplessness, sadness about her diagnosis, loss of independence, distrust of (and dependency on) the strangers taking care of her, anger at God, separation from loved ones, anxiety about the meaning of her illness and her future, pain, and other physical discomforts. All of these human emotions must be considered in understanding and helping a patient like Ms H.
Of course, this vignette also suggests a set of psychiatric questions, as well. It sounds like she had an agitated delirium post-operatively. Was her subsequent apathy and withdrawal worsening depression only, or was there also a hypoactive delirium that contributed to her withdrawal and disengagement? Grief, fear, and sadness can be extremely intense and also normal after a new cancer diagnosis, and often persist for many weeks. Over time, most patients adapt and come to terms with their diagnoses, finding a way to live with this “new normal” state. This patient had risk factors (her past depression) for developing a major depression in response to this difficult situation. In this circumstance, she might need urgent psychopharmacologic intervention.
Caring for patients like this, even those, or perhaps, especially those, who are suffering greatly with a new diagnosis, can be rewarding because there is so much we can do to help. The first task is to develop a relationship with the patient. In the ICU, this may be done through asking about pain and comfort, and advocating for attention to these issues. No psychiatric intervention can be effective if a patient is in pain. Sometimes we bring a patient a warm blanket; at other times, we explore feelings and concerns about their illness and treatment. The next step is a careful assessment that permits us to make a psychiatric diagnosis. If a patient has a psychiatric disorder, we treat it because patients can’t do the psychological work of coming to terms with a life-threatening illness while they are profoundly delirious or depressed. If the patient can’t engage verbally, our human presence can be a powerful healing force. As the patient recovers from the physical insult of surgery and, perhaps, a post-surgical delirium, she may become more able to engage. At this point, a dialogue with the patient can support the patient’s inner resources and strengths in coping with past adversity and address fears and concerns to help support healthy adaptation to a life-threatening illness.
;)
[click image to view]
Al Margulies, MD
Entering HMS as an eager medical student, Dr. Margulies remained for his psychiatry residency at Mass Mental Health Center, staying there for the Semrad Teaching fellowship before moving to Cambridge to run the medical student programs. At Cambridge he ran the psychiatric outpatient services, helped create the Program for Psychotherapy, and is now Associate Chairman of the Department of Psychiatry. Essentially, he is an HMS purebred from start to finish, and his diverse accomplishments reveal how he has been a remarkable source of inspiration and guidance for the institution and its inhabitants for nearly three decades.
At the Cambridge Health Alliance Dr. Margulies still directs medical student teaching (alongside Dr. Todd Griswold and Pat Carr), in addition to fulfilling his role as Associate Chairman. He has always maintained a general psychiatric practice, which includes a strong emphasis on psychoanalysis. His involvement in psychoanalytic education has led to his sitting on the faculty of three psychoanalytic institutes in Boston. Somewhere along the way, Dr. Margulies’ commitment to education earned him at least four distinguished awards for excellence in teaching students of all levels. Despite these accolades and successes, what truly distinguishes Dr. Margulies’ accomplishments from other outstanding leaders is the unique way in which he values education and strives to instill this concern in the next generation of doctors.
Sitting in Dr. Margulies’ office at Cambridge, one is surrounded by several paintings, quietly referencing the underlying ability of art to reveal phenomenological truths of individuals. Dr. Margulies described Van Gogh, for instance, as “so recognizable…” that when you look at one of his paintings “you know you’re in his world”. He explained Van Gogh’s gift as “illuminating an aspect of the world you wouldn’t know without him”. Psychiatry, like art for Dr. Margulies, compels us to question how to observe and take in another’s worldview. This fascination with the unique way in which people experience the world was one of the main factors leading Dr. Margulies from his Virginian childhood of cultural contradictions – in a Jewish family assimilating to southern American culture - into psychiatry, where patients continued to experience the same world in drastically different ways. And it seems that this desire to understand the basic human experience of others is precisely what has enabled Dr. Margulies to excel in teaching others. Dr. Margulies has taught every aspect of HMS psychiatry (from the ICM to the 700 course), sustaining his direct involvement with students by composing the schedules of every student entering his clerkship, and seeing patients on the wards with students twice a week.
His scholarly interests converge at the margins of psychiatry, psychoanalysis, existential and postmodern studies, and “the search for self and free will on a sea of determinism.” Dr. Margulies Empathic Imagination is not only the title of one of his books, but perhaps an apt description of one of his most influential talents. In his effort to sustain what he recognizes as the true essence of HMS – its gift of possibilities – Al Margulies’ blend of philosophy, empathy, scientific curiosity, and appreciation for his memorable HMS education have molded him into one of Boston’s most unusual and dedicated psychiatrists and educational leaders.
Heather Adams
If you have not been involved in medical student teaching before or wish to re-engage, please contact Jon Alpert (jalpert@partners.org) or Steve Schlozman (sschlozman@partners.org) or the director of medical student education within your own department. In addition to teaching within the formal courses, including the psychopathology course, neuroscience courses, the psychiatry clerkship, Patient Doctor I-III courses, and psychiatry elective courses, faculty may play a crucial role in medical student education as OSCE examiners, developing virtual cases, serving as mentors, providing opportunities for shadowing in clinical practice or research, developing videotaped or other teaching resources, and as discussants at the student interest group in psychiatry lunch talks.