Psychodynamic lessons in liaison psychiatric teaching for medical students

Medical students at University College Hospital are attached to medical firms during their first clinical year, where they receive one hour of liaison psychi atric teaching every week. The teaching usually takes the form of a presentation to the group of a patient seen by one of the medical students on the medical ward, followed by a discussion with particular emphasis on the doctor-patient relationship. The following account is a set of five sessions with a group of medical students during their five week attachment to a medical ward and illustrates by means of clinical material, and the doctor-patient relationship how the emotional development and change in a student's attitudes and role is a reflection of the patients' problems presented.

Medical students at University College Hospital are attached to medical firms during their first clinical year, where they receive one hour of liaison psychi atric teaching every week. The teaching usually takes the form of a presentation to the group of a patient seen by one of the medical students on the medical ward, followed by a discussion with particular emphasis on the doctor-patient relationship.
The following account is a set of five sessions with a group of medical students during their five week attachment to a medical ward and illustrates by means of clinical material, and the doctor-patient relationship how the emotional development and change in a student's attitudes and role is a reflection of the patients' problems presented.

Clinical material
In the first session, the patient presented was a 68-year-old man, who complained of vomiting and diarrhoea which was initially diagnosed as food poisoning, but later as prostatic carcinoma with secondaries. According to files from a previous hospital, the patient had been diagnosed as having a prostatic tumour three years earlier. The patient and his family appeared to be completely unaware of the cancer in his body, both in the earlier admission diag nosed in his mind as "poison in his heart," and with this admission where the diagnosis was given as "food poisoning." There does seem to be an uncon scious knowledge of a contamination of his body, but a denial of the true facts of his illness. The dilemma the students faced in their first session with me was whether to collude with the patient and doctors in the denial of the problem, and identify with "robot consultants" (to quote a student), in order to avoid the very difficult feelings and issues in their role as medical students, and, later doctors, or to tell the patient about the seriousness of his ailment with its enormous emotional impact.
In the second session, a 47-year-old Pentecostal minister was presented by the medical student. He complained of loss of appetite, urinary retention and chest pain. In fact, the patient had initially presented in casualty, in a very dishevelled state, with tachycardia and a tremor. He was diagnosed as suffering with "alcoholic withdrawal" and sub sequent investigations disclosed no pathology. The social history of the patient was very revealing: he had given up his job as a minister to get married to a woman from Mauritania, only to discover three months later, that "she had been using him" to gain a visa, through marriage, to enter England. She had also used his money, so he was now penniless, and therefore had been placed by a social worker in a single men's hostel. The medical symptoms seemed to fade in significance compared to his psycho-social, problems, but here was the rub; could he talk, discuss or air his problems in a trusting, open and honest relationship? So far, he felt used and trapped by the doctor (he denied alcohol abuse), by the social worker, (he did not want to go back to the hostel) and by his wife.
The medical students were placed in the same dilemma; could they trust the group as a place to discuss their feelings and difficulties; talk about psycho-social problems without being dismissed as irrelevant? Could they entrust the seminar leader and the other members of the group with their feelings and decisions?
The third session involved a young man, single, living in a hotel, with a history of asthma and diabetes, now presenting with a productive cough of green-brown sputum, breathlessness and a tempera ture. He was diagnosed as having pneumonia and started on antibiotics. It all seemed reasonably straightforward, but there was some confusion and surprise in the group's collective mind about the patient's premature removal from the ward: "Why was he discharged so soon?". There was some dis quiet among the nursing staff that "he was not supposed to be admitted," "he was not to be on this ward," "a trouble-maker," "a drug addict". The students' bewilderment and astonishment about this case, "We feel we are invading their space, getting in their way," represented their own anxiety about being accepted on the ward as medical students, or as new members of the group. Even with a legitimate illness, the patient was unacceptable. What role would the student have to act out to be included in the group or ward?
The patient presented in the fourth session was debated and discussed in the subsequent session as well. She was a 74 year old woman, Mrs X, who presented with carcinoma of the pancreas. She was described by the medical student as "intelligent, articulate and friendly"; he felt comfortable to be in her presence, did not want to hide behind the shield of his white coat and was "ready to let her talk and have power in the relationship." She appeared extremely healthy, looking younger than her age. The association between the student and patient quickly developed into a close and intimate rapport where the student was kissed on arrival and a very trusting relationship emerged, where each partner was appreciated. However, it soon became clear that Mrs X was beginning to take control of the relation ship and indeed, the whole ward; "she controls the conversation, and is a very organised person who seems to enjoy bossing us around." The student felt frightened by her and began to wonder "where am I going wrong?" He felt helpless; reluctant to challenge her, unwilling to upset her and began to avoid her in the ward.
In fact, the patient managed to turn tables on the medical student by trying to look after him as if it were he who was the helpless one. Byestablishing this intimacy, it makes the student feel like a little boy, rather than a mature grown-up doctor, and allows the patient to retain dominance. If she allows him to be doctor it will bring home to her the realisation of her position as the terminally ill patient suffering with cancer. By rejecting his 'white coat' status he has joined himself with the patient's denial of her suffer ing and imminent death. Now faced with his identity problem and uncertain of where his allegiances lie, his plea of "Where am I going wrong?" could be interpreted as "Who am I?" In the group discussion, the dependence on the group leader for the answer, rather than trying to identify in the seminar the problems latent in the doctor-patient relationship, reflected the internal conflict of dependence-independence in the students.
In the fifth and final session the student reported that he had made contact with Mrs X again as she 697 was about to be discharged from hospital and he wanted to say good-bye to her. This seemed an important shift in his attitude to the patient; that perhaps he had gained an understanding of his own feelings and needs as well as his patient's responses.
The student further reported that not only had he repaired the relationship but that the patient had invited him and a fellow student home for tea. This created great excitement with plans to buy her flowers and chocolates; each partner feeling appreciated and valued by the other. However this engendered further conflicts about the possibility of stepping out of the boundaries of their medical roles. Perhaps the student identity is so fluid it can easily be disowned or held on to, and though the group discussion had made it possible for the students to be able to assume the role of the doctor, the student is seduced into identifying with the patient again.

Comment
The group created a space for the students to talk about the problems and conflicts in their new position as medical students, where it seemed more important to define their role, rather than make decisions of whether to tell a patient their diagnosis or not. As the sessions progressed, it became clear that a pattern was emerging in which the problems and difficulties of the patients were a reflection of a student's development on the ward and in the group. The cases illustrate the dilemmas and con flicts of the students arriving on the ward for the first time, discovering the psycho-social climate of the medical wards and facing the difficulties of death and serious illness. Perhaps, more importantly, the students' own conscious and unconscious attitudes and reactions emerged out of these issues and were mirrored in the patients presented for discussion in the group.