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Articles    H2'ed 4/16/10

Psychology and Health Care Reform

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She had incorrectly thought that psychologists would be excited to learn psychopharmacology (and basic science) in the way it is taught now in U.S. medical schools. Was she ever wrong!

Medical schools have come to the realization that learning basic science in isolation from clinical work is basically time wasted. Retention of the information is poor. While medical students are legendary for their memorization skills, most of the material is forgotten after the exam. This was my experience and that of my colleagues. The basic science we remembered came later, when we were treating patients and read about the basic science aspects of their disease. We remembered the information because it was relevent to a real person whom we know. We had long forgotten our basic science classes. Thus, some years ago, beginning with the University of New Mexico (Harvard rapidly followed and took most of the credit), courses in the separate disciplines were largely eliminated. Instead, medical students work together in small groups with a mentor. They spend 4 to 6 weeks perorgan system focusing upon several common diseases with real patients to interview and examine. They interact with relevant faculty as they explore all aspects of all illness, including the underlying changes that occur in cells, its biochemistry, genetics, physiology, epidemiology, and more. At the same time, students learn how to treat the illness. Having real patients packs the information into a narrative, the best means of memory storage. Doing their own research, presenting their findings to their mentor and fellow students, and answering questions like those that will be posed to them in practice are exciting ways to achieve competence in a field in which there is always too much to know and what is known is continually changing. My friend was scheduled to teach a class on the body anatomy, physiology, endocrinology, etc. (they get only one 2 unit course on everything below the brainstem). She proudly showed me her plan. She had started with the lungs. She divided her six students into two teams. One team had a COPD (chronic obstructive pulmonary disease) patient, while the other had an asthma patient. Their final job was to pick medications for these patients that would have the least interactions with the underlying illness and the medications used to treat it. Their task was to choose a drug for (a) depression, (b) anxiety, (c) mania, (d) psychosis, and (e) sleeplessness. They were to speculate on CAM (complementary and alternative medicine) therapies that the patients might also be using and to discuss other non-medical therapies that might be helpful. In the process, they were to wander around the hospital (they all worked at the same hospital) and meet their counterparts who interacted with such patients. They were to visit the pulmonary function lab and watch the technicians assess lung function, finding out how these two diseases were differentiated. They were to go to the pathology lab and watch a lung being autopsied and examined under the microscope in a frozen section. They were to talk to pulmonologists and respiratory therapists and learn as much as they could about how these diseases affected the normal structure and function of the lung (which required them to learn something about its normal structure and function). During class, each group would take turns presenting to her and to the other students what they had learned and the conclusions they had made. She would correct any errors and comment on their choices of medications and conclusions. She was also available all week as a consultant in case they got stuck in any aspect of their discovery. My friend wanted the psychologists to see how physicians learn and in the process, to learn how to think more like physicians (see the book, How Doctors Think). She had admonished the students to avoid spending more than six hours for each student during the week on this task since it was only a two credit course. She thought they could get carried away with the excitement of learning in this manner and of discovering the body and its mysteries.

The students showed my friend! Unanimously,all six went to the Chair of her Department and demanded that she be replaced as the teacher of their course. She showed me the letter they wrote in which they accused her of wasting their time, both in class, and outside of class. They accused her of didactic negligence. They demanded powerpoint presentations and a class of basic scienc e without any clinical correlation. They asserted that her assignments were ridiculous. Her Chair did replace her as a their teacher, giving the class to a retired pediatrician who agreed to present didactic powerpoints of basic science. My friend resigned in humiliation.

Later she told me that the pediatrician had told her that mostly the students slept through his lectures and that he was teaching on a high school level about what is a fat, what is a protein, what is a carbohydrate, etc. He had no confidence that these students could ever treat a patient or ever should. He had concluded that they were overworked in the daytime and had conspired to find a way to do the least work possible in "night school", for which their employer was footing the bill and requiring them to go. By demanding a mid-term and a final, they could agree to set the curve at a level in which they were all essentially equal. Making presentations would have required them to actually work and learn.

My friend's replacement teacher agreed with her that he would, of course, give them all "A"s, regardless, because it was too much of a hassle not to do so. The students had won.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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