Robert F. McFadden, MD Alexandra H. Sawicki, PGY1 Emory University

1. Classifying reactions to difficult patients - A reproducible didactic conference for medical students Robert F. McFadden, MD Alexandra H. Sawicki, PGY1 Emory University

2. Abstract We describe a one hour interactive conference given during medical students’ psychiatry clerkship. We introduce a framework for examining, classifying, and understanding reactions to difficult patients. This exposes students destined for all medical specialties to a consistent method of examining patient interactions. This conference brings psychodynamically-oriented faculty into contact with the entire student body in the service of improving students’ ability to respond to, diagnose, and care for patients. Some medical schools have held group discussions of problematic patient encounters without a structured didactic component. Prior to our conference, taught once per clerkship, students are surveyed and asked to describe a troubling psychiatry patient encounter. Information is gathered about what troubles students, and how the students reacted. This retrospective survey encourages growth of students’ observing ego regarding their feelings and reactions as a physician. During the real-time conference, we teach students to distinguish between three types of reactions: justified reactions, projective identification reactions, and counter-transference reactions. We lead students through a problem-based learning exercise to practice applying this concept. Time is allowed for discussion of how this classification can guide students after a troubling patient encounter. This conference addresses the important, often ignored issue of students’ reactions to troubling patient encounters with a systematic and reproducible classification system that could be taught in an hour-long lecture at medical schools throughout the country. This will give students a lifelong protective layer of insight that will allow them to respond in healthier, more empathetic ways to patients.

3. Background • Learning clinical medicine is a stressful process, and learning clinical psychiatry has been shown to be particularly stressful1,2 • Clerkship instructors have used several teaching methods to help students more effectively interact with difficult patients2,3 • Pessar et al. reported on sources of stress to third-year students in the psychiatry clerkship2 • Pessar et al. offered students a supportive conference to discuss troubling patient encounters. They found that the numbers of students reporting “scared” or “negative reactions” decreased over the course of the rotation.2 • Our conference teaches third-year medical students a framework for thinking about their reactions to difficult patients. We describe three common kinds of reactions students have to patients. We then use a problem-based learning (PBL) technique to teach students to identify these kinds of reactions within a clinical case. The goal of our conference was not necessarily to decrease negative reactions, but to improve students clinical skills and allow them to respond to patients in healthier, more empathetic ways.

4. Methods Third-year medical students on their psychiatry clerkship participated in a one-hour conference on classifying reactions to difficult patients. Students were surveyed one week prior to the conference to gather reports of particularly troubling encounters. Themes seen in the surveys were discussed in the instructor’s introduction to the conference. The conference opens with an introduction to three common kinds of reactions to patients: justified reactions, projective identification reactions, and counter-transference. Then students are divided into smaller groups for a problem-based learning case, in which they practice distinguishing between types of reactions. The conference concludes with student discussion of the problematic encounters from the surveys.

5. Result Pre-conference survey Structure of the Conference I. Topic Introduction II. Justified reactions, Projective Identification, and Counter-Transference III. Problem Based Learning Case (PBL) IV. Open discussion of student submissions Feedback on conference

6. Pre-Conference Survey Problem Patient Encounter Form Part I: Describe a patient encounter during your psychiatry rotation that troubled you. (What was the purpose of the interaction? Where did it occur? What happened? What troubled you about it?) Part II: Please describe the behavior of the patient. Give 2 adjectives to describe the patient. “The patient was…” 1. 2. Part III: If you can remember, describe your own response at the time to this interaction. Give 2 adjectives to describe yourself during the above interaction. “During the encounter I was…” 1. 2. Part IV: Describe, as best you can, your current feelings about this patient encounter. Please write the patient’s diagnosis if known.

7. Conference Introduction • Psychiatric pathology is interpersonal – existing between the patient and others • The infectious nature of psychiatric pathology is rarely discussed in medical school, which is a serious problem • Students are often left feeling burdened, ashamed, concerned, and guilty because of their reactions to patients on their clerkship. This may ultimately result in students having negative attitudes about psychiatry as a career, or about the patients themselves. Goals for the conference: • Provide improved care for patients • Use reactions as a tool for diagnosis • Respond in healthier, more empathetic fashion to patients

8. Three Kinds of Reactions Justified Reactions • Based on social norms and rules • Conscious reactions to things the patient is consciously doing • Feelings we are usually immediately aware of and mostly comfortable responding to • As doctors our usual reactions to sick people are sympathetic and caring • Sometimes our reactions feel negative when dealing with certain sick or regressed patients • Such reactions are not “bad” or “problematic,” rather they are an important source of information • Example: appropriate fear reaction

9. Three Kinds of Reactions Projective Identification • Ego defense mechanism • Inter-personal (versus projection which is intra-personal) • Thought or emotion is deposited in the student-physician • “Receiver” actually experiences the projected thought or feeling • PI is unconscious to the patient, but student is conscious of reaction • Example: projecting USMLE anxiety into others

10. Three Kinds of Reactions Counter-transference • Brief discussion of transference • The “transference of feelings” onto the student cause him/her to have a reaction • Reaction is based on student-physician’s unconscious inner-conflicts • Not ALL reactions that student-physicians have to patients are counter-transference • Example: Inappropriately decreased fear response to a patient due to patient’s similarities to one’s brother

11. Student Aid for Classifying Reactions

12. Problem Based Learning Case (Split the group up into small groups of four, and have them sit together so they can easily chat. Hand out signs labeled A-D. When there are questions, give the students a moment to chat, and then ask for a member of each group to hold up the groups answer) Mr. D is a 32 year old man who has called the Psychiatry Outpatient Clinic for an intake. He meets with Dr. C. At the initial appointment, he reports experiencing frequent 10 minute episodes of extreme tension that make him fear he is having a heart attack. He recently went to the ED with these symptoms, and a workup was negative. He has been having these episodes for two years, but they have been getting worse. He is now so fearful of experiencing them, that he hesitates to leave his apartment. “When I’m here, at least I know I could get help.” In the past month or so, he has started crying daily and feeling blue and helpless. He is losing weight and having trouble sleeping, and is not participating in his usual social activities. He denies suicidal thoughts or plans. He reports difficulty maintaining friendships even before the past two years, but “…now it’s impossible.” What is the primary diagnosis? A. Panic Disorder with Agoraphobia B. Major Depressive Episode C. Personality Disorder

13. One week after his intake interview Mr. D presents for his second appointment. He arrives early and appears very anxious. He is pale, ill-appearing, and startles when the door to the waiting room opens. Once seated in Dr. C’s office he remains quiet. Though Mr. D was able to describe his panic and depressive symptoms in his intake interview, he is more withdrawn today. His responses to Dr. C’s questions are short, consisting of a “yes” or “no” with little elaboration. He eventually states that he hadn’t planned on coming a second time because he is not optimistic about therapy being helpful for his problems. “People in my family have seen doctors for this and it hasn’t helped.” Dr. C asks him to tell more about this, but Mr. D refuses and continues to appear anxious. He fidgets, avoids eye contact, and concedes to Dr. C, “I must be irritating you.” After a period of silence, Mr. D jumps to his feet, says that he must leave, “I can’t take this” and exits the office. Dr. C is frustrated with the patient’s withdrawal from the interview and his rejection of her treatment. She thinks “Well, no wonder he never feels better. He probably never follows through on his treatment. I set aside this time to help him…I’m annoyed.” What type of reaction is Dr. C experiencing? A. Justified Reaction B. Projective Identification C. Counter-transference

14. About two months into the treatment, Mr. D has experienced little improvement in the intensity of his panic and depressive symptoms. During a therapy session, he is intensely emotional and seems to be unraveling mentally. Dr. C begins to experience some panicky feelings. She thinks “What will I do if he really loses it? I hope he has his Klonopin in his bag, or I’m screwed!” She begins to fantasize that he will never improve, and she’ll be embarrassed to present him at case conference. She considers claiming that she has food poisoning on the day she is schedule to present his case. Paradoxically, as she becomes more upset, the patient seems to calm down. What type of reaction is Dr. C experiencing? A. Justified Reaction B. Projective Identification C. Counter-transference

15. About one year into the treatment, Mr. D has improved somewhat. Although his symptoms are better controlled, he is a psychically fragile person even at his best. Dr. D has worked hard with him - reading about his pathology, asking for consultation, being available to him by phone when necessary. Now, Dr. D is taking a well deserved vacation - she is going to Myrtle Beach with some of her high-school friends for a bachelorette party. However, she is concerned about Mr. D missing his weekly appointment. Because she cares about him, she arranges to meet with him at 6AM on the day his flight leaves. “This will allow me to provide him treatment, and I’ll still be able to make my plane.” The day of her flight arrives, and she wakes at 8AM, feeling great. As Rapid Rover takes her to the airport, she gets a call from the clinic front desk staff. “There is a man here for you, he says you had an appointment 3 hours ago. He’s really upset.” What type of reaction is Dr. C experiencing? A. Justified Reaction B. Projective Identification C. Counter-transference

16. Experiential discussion • Students are encouraged to discuss their experiences with, and reactions to, difficult patients. • Alternatively, if students are hesitant to do this, we encouraged discussion of the final section of the PBL. What might Dr. C say to the patient at their next appointment? • Student feedback on this didactic conference has been very positive in student end-of-clerkship surveys thus far.

17. Conclusion • Discussion of clinicians reactions to patients often focuses on counter-transference reactions without making reference to other reaction types.4 • Including justified reactions and projective identification reactions importantly acknowledges the variety of ways a student may react to a patient. By giving students a systematic approach to processing their reactions to patients this conference encourages students to provide better care for psychiatric patients, use their own reactions to patients as diagnostic tools, and to respond in healthy empathetic ways to psychiatric patients. • This conference encourages students to develop insightfulness and diagnostic skills after difficult encounters with patients, rather than feeling negatively about the patients, psychiatry, or themselves as clinicians.

18. References • Kris K: “Distress precipitated by psychiatric training among medical students.” American Journal of Psychiatry 1986; 143: 1432-1435. • Pessar L, Pristach L, Leonard K: “What Troubles Clerks in Psychiatry? A Strategy to Explore the Question”Academic Psychiatry, 32:3, May-June 2008. • McNeillyD, Wengel S: “The ER Seminar – Teaching Psychotherapeutic Techniques to Medical Students” Academic Psychiatry, 25:4, Winter 2001. • Muskin P, Epstein L: “Clinical guide to countertransference.” Current Psychiatry April 2009, p. 24-32.