Teacher-student relationships in medical education: boundary considerations.

BACKGROUND: Despite recent attention to the area of student mistreatment, there has been less emphasis on the problem of excessive or inappropriate intimacy between teachers and students. Although a certain amount of closeness to faculty is important to the professional socialization of students, excessive or inappropriate closeness can be coercive because of the power differential between teacher and student. This can cause discomfort, discrimination, or psychological and academic harm to students, who often feel too intimidated to express concern. AIMS: We provide a framework that allows both faculty and students to discuss these issues more openly and to consider constructive strategies in their own settings. METHOD: We collected examples of boundary issues that individuals had experienced or knew that others had experienced in teacher-student relationships. RESULTS: Examples of excessive intimacy include patterns of expressing favoritism for personal reasons, disclosure about personal or academic problems experienced by the teacher, and socializing with selected students, up to and including dating and consensual sexual involvement. CONCLUSIONS: Personal and situational risk factors may make teachers or students more prone to cross healthy boundaries. Education about boundary issues, including discussion of case vignettes, may help build awareness and thus help foster more balanced teacher-student relationships.

A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology department.

OBJECTIVE: The growing use and complexity of endoscopy procedures in GI units has increased the need for good patient preparation. Earlier studies in this area have focused on the psychological benefits of patient education programs. The present study was directed at determining cost-effectiveness of a patient education program. METHODS: A prospective, randomized, controlled design was used. The patient population consisted of 142 patients aged 18-90 yr referred for an endoscopy procedure. Ninety-one (64%) participated in a targeted educational session conducted by a dedicated departmental nurse (group 1), 38 (27%) did not (group 2), and 13 (9%) received telephonic instruction (group 3). Before the endoscopy, all patients completed a questionnaire covering background data, endoscopy-related variables, anxiety level, and satisfaction. Patient cooperation and success/failure of the procedure were documented by the attending nurse. RESULTS: Male gender, previous endoscopy, and explanation from the referring physician were associated with a low level of anxiety (p < 0.05). There was a significant association between attendance in the education program and success of the endoscopy (p = 0.0009). Cancellations of procedures because of poor preparation occurred in 4.39% of group 1 in comparison with 26.31% and 15.38% of groups 2 and 3, respectively (p = 0.005). The overall cost of the procedure was reduced by 8.6%, 8.9%, and 5.5% for gastroscopy, colonoscopy, and sigmoidoscopy, respectively. All participants expressed satisfaction with the brochure. CONCLUSION: A pre-endoscopy patient education program apparently increase patient compliance, thereby decreasing both the need for repeated examinations and their attendant costs.

Recruitment into psychiatry: increasing the pool of applicants.

OBJECTIVE: To demonstrate that it is possible to identify the cohort of students in their first year of medical school from which future psychiatrists will be recruited. METHOD: During a 3-year period, all first-year medical students at the University of Maryland completed a form indicating their specialty preference. Of those students, 403 pursued the regular psychiatry curriculum, and 34 participated in an enriched behavioural science and psychiatry program. Specialty was chosen after graduation. RESULTS: The higher the first-year student ranked psychiatry as a preferred specialty, the more likely the student was to choose psychiatry as a career after graduation. This was true both for students in the regular psychiatry program and for those in the enriched program. Students in the enriched program were significantly more likely to choose psychiatry as a career than were "regular" psychiatry students who gave psychiatry the same ranking in their first year. Freshman students who ranked psychiatry 4th or lower were not likely to choose psychiatry, no matter how much encouragement they received from their psychiatry departments. CONCLUSIONS: 1) Specialty preferences in the freshman year are predictive of future career choices. 2) An enriched medical school program in psychiatry can increase the number of graduates choosing careers in psychiatry. To help resource-poor medical schools increase the number of American medical graduates choosing psychiatry, the authors propose 2 inexpensive enriched programs.

Medical school electives and recruitment into psychiatry : a 20-year experience.

Part of psychiatry's recruitment problem is a result of defections among students who were planning careers in psychiatry when they entered medical school. The authors present data from a 20-year (1974-1993) experience at the University of Maryland that shows that students who expressed a preference for psychiatry as a career in the freshman year were four times more likely to enter psychiatric residency training after graduation if they participated in the Combined Accelerated Program in Psychiatry (CAPP), a 4-year psychiatric elective program, than if they pursued the regular undergraduate psychiatric program. More than 20% of the CAPP students who preferred nonpsychiatric careers as freshmen were "converted" to psychiatry and later entered psychiatric residency programs. Recent changes in the ideology and economics of our profession have neither lessened the popularity of the CAPP nor diminished its apparent ability to shelter students preferring psychiatry from the stigmatizing experiences of medical school.

[Severe neuropathy in a young diabetic].

A 19-year-old woman with insulin-dependent diabetes mellitus (IDDM) of 3.5 years duration had been suffering from recurrent episodes of diabetic ketoacidosis (DKA), dizziness, and weight loss (16 kg, 29%) for 6 months. History and physical examination gave evidence of severe peripheral and autonomic neuropathy. Radionuclide retention on gastric emptying test at 60 min was greater than 90% (normal < 60%). On autonomic cardiovascular testing there was evidence of both parasympathetic and sympathetic damage. There was no evidence of nephropathy or retinopathy. Optimal diabetic control using 4 insulin injections (2 u/kg/day) and high-dose cisapride terminated the vomiting, and she regained the weight lost within 5 months. This case is unique in that severe diabetic neuropathy followed relatively soon after onset of disease, without other microvascular complications. The correct diagnosis of gastroparesis as the cause of the recurrent DKA and weight loss, and the specific prokinetic therapy and nearly normoglycemic control of the diabetes led to dramatic clinical and functional improvement. Specific prokinetic therapy and the nearly normoglycemic control of the diabetes led to dramatic clinical and functional improvement. Gastroparesis can cause recurrent DKA even in young patients with IDDM of short duration.

Inspirational recruitment and the Maryland Plan: overcoming the stigma of public psychiatry.

University-trained psychiatrists frequently avoid public-sector employment because they do not wish to be associated with stigmatized institutions. Inspirational recruitment--the elevation of poorly paid and unpleasant work to a noble cause--is one way of temporarily destigmatizing state psychiatry. The authors describe the impact of one such effort, the Maryland Plan, on recruitment of graduates of the University of Maryland psychiatric residency program into the state's psychiatric system. Significantly more graduates entered state psychiatry in the 15 years after the plan was implemented in 1978 (78 of 164 graduates, or 47.6 percent) than in the eight years before (seven of 57 graduates, or 12.3 percent). Data indicate that low salaries did not hurt recruitment, nor did doubling the stipends prevent the majority of recruits from leaving the public sector after a few years of service.

Mental health services for medical students: perceptions of students, student affairs deans, and mental health providers.

PURPOSE: To examine (1) whether there is any consistency among medical schools in mental health services provided and (2) how these services are perceived by student affairs deans, mental health service providers, and the students themselves. METHOD: Questionnaires were sent in October 1991 to the student affairs dean (or director), the individual responsible for student mental health services, and a student representative in each of the 126 U.S. and Canadian medical schools. Data were sought regarding personnel, individuals served, location, hours, administration, funding, confidentiality, administrative referrals, and respondents' suggestions for improvement. Possible differences among the three groups of respondents were tested by chi-square. RESULTS: Responses were received from 75 student affairs deans, 53 mental health providers, and 30 students. There was much diversity among schools in services provided, especially in the areas of administration and funding. Although perceptions of the three respondent groups were often the same, they differed significantly in a number of areas. Suggestions for improvement of services involved funding, personnel, hours, confidentiality and privacy, specialty services, preventive and support programs, and visibility. The suggestion most frequently made by the students was for increased information and visibility. CONCLUSION: The differences among schools coupled with the differing perceptions within schools indicate a need for a comprehensive consideration of what kinds of mental health services are needed and how they can best be made accessible to a diverse body of students experiencing a variety of academic and personal challenges.

Boundary issues in teacher-student relationships.

Increasing concern about therapist-patient sex has led to a consideration of boundaries in all trust-based relationships, which always include elements of power and dependency. Such relationships include those between teacher and student, especially those involving research or clinical supervision. Teacher-student relationships differ from those between therapist and patient because of the collegiality considered important for the student's development. Yet, both share the objective of fostering independence of the "client." Therefore, teachers need to find a balance of nurturance and separateness in their relationships with their students, so that the students can carry that modeling into their own careers.

The role of medical school electives in the choice of child psychiatry as a subspecialty.

Part of child psychiatry's recruitment problem stems from defections among medical students who were planning careers in child psychiatry when they entered medical school The authors present data showing that between 1974 and 1984 University of Maryland Medical School graduates specializing in psychiatry were more than twice as likely to enter fellowships in child and adolescent psychiatry if they were participants in the Combined Accelerated Program in Psychiatry (CAPP) as medical students. The CAPP, a 4-year medical school track that contains a strong child psychiatry component, appears to prevent the erosion of students' interest in child psychiatry.

Institutional resources for medical students in committed relationships.

Medical students in committed relationships must balance the demands of the rigorous educational process against such things as their partners' educational and professional priorities, childbearing decisions, domestic and family obligations, financial and geographic constraints, and the desire simply to do things together. Couples may also have to deal with the relative intimacy that often develops between students and their colleagues who function in close, often stressful settings and who tend to rely on each other for emotional and intellectual support. The variety of these challenges has increased as student bodies have become more heterogeneous in age, gender ratio, and cultural background. Medical schools can help couples cope with these challenges by developing policies and programs responsive to the needs of couples and by providing opportunities for partners' involvement in the institutional life of students.

Qualifying phrases as a measure of spontaneity in speech.

Although investigators have attempted to define the paralinguistic characteristics of spontaneous speech, there have been no systematic attempts to study its verbal reflections. An experiment comparing extemporaneous and impromptu speech samples of 10 freshman medical students showed that, of 10 verbal categories, only qualifying phrases significantly differentiated the two levels of spontaneity. A second study compared post-World War II presidential communications of different degrees of spontaneity. Speech samples were taken from inaugural addresses of seven presidents, and from both introductory remarks and responses to questions at their press conferences. The proportion of qualifying phrases significantly decreased as the amount of preparation increased, confirming the results of the student experiment. The use of qualifying phrases appears to represent, in part, an attempt by the speaker to avoid silence while retrieving and encoding memories from long-term storage.

Female orgasmic experience: a subjective study.

Human female orgasm was studied by collecting and analyzing the subjective orgasmic histories of 30 women, ages 18 to 59 years. Virtually all of the 93% who reported they had experienced orgasm also reported some level of conscious control over whether or not they reached orgasm. Women differed widely as to preferred types of physical stimulation and/or mental activities to facilitate orgasm. Orgasms were experienced as centered in the clitoral and/or vaginal areas. Women over 40 were more likely to have experienced orgasm in more than one anatomic site than were women aged 18 to 29. Marital status, religion, occupation, educational level, experiences of pregnancy and childbirth, various reported characteristics of relationships with partners, and early sexual experience were not associated with where orgasm is experienced within the body or with other variables of adult orgasmic experience. The variation among women as to how orgasm is best reached, differences in where it is experienced within the body, and the reasons why an individual woman experiences orgasms differently over time remain poorly understood phenomena.

Intensive medical student support groups: format, outcome, and leadership guidelines.

The authors report on a five-year experience with process-oriented discussion groups at annual four-day, off-campus retreats attended by students, faculty members, and "significant others." Group sessions comprised 17 hours of each retreat, which also included community activities and recreation time. Group leaders represented a diversity of professional backgrounds. In response to questionnaires sent from one to two months after the retreats, participants rated group experiences highly, although they also considered a significant amount of time for unstructured interpersonal interaction and recreation important. Participants enjoyed meeting students and faculty members in a relatively "role-free" setting, and students derived an enhanced sense of self-awareness from group discussions. The most highly valued group leader behaviors were participation as a group member, facilitation of interpersonal communication, and attention to group members' needs. Guidance and direction by the leaders were also considered valuable, provided that they did not impose inappropriate expectations on their groups.

Teaching home monitoring of blood pressure to adolescents.

A videotape and lecture method for teaching the self-measurement of blood pressure were compared in twenty, 13- 18-year-old adolescents. The time of instruction and evaluation were monitored in order to assess acquisition of skills and cost-effectiveness. Both methods of instruction were equal in respect to acquisition of skills. The videotape method of instruction was more cost-effective than the lecture method in populations of more than 23.9 patients per year, as long as videotape equipment was already available. If the equipment needed to be purchased, the videotape method became more cost-effective with populations of greater than 93.6 patients per year. It was concluded that health care teams should consider the videotape method as a cost-effective means of instruction when videotape equipment is available. In addition, a health care team which evaluates and follows a substantial number of patients per year for hypertension could realize considerable savings in the use of the newer media.

Stress, coping behavior and resistance to disease.

Psychosocial factors affect resistance to a wide variety of diseases in animals. Stimuli often assumed to be noxious (e.g., electric shock, isolation housing) have been found to exert either potentiating or protective effects on an animal's response to potentially pathogenic stimulation. This variability has often been attributed to the influences of these stimuli on aspects of neuroendocrine or immunological function which are related to specific forms of pathogenic stimulation. The impact of a particular form of stimulation on the physiological state of the organism is also determined by the ability of the animal to cope with the stimulus environment. Factors shown to influence have included: (a) other aspects of the immediate environment at the time of stimulation; (b) prior experience with the same or other forms of stimulation; (c) the animal's ability to control its relationship to the stimuli by learning to escape or avoid them; (d) the availability of relevant feedback regarding stimulus onset (e.g., warning signal), and (e) the stage of the disease process at which stimulation is imposed. These findings by various investigators indicate that it may be inappropriate to place a priori value judgements on any form of psychosocial stimulation or stress either as conceptually or operationally defined. The adaptive value of the psychosocial environment will depend upon its perception by the animal, the animal's ability to cope with the stimulus environment, and the particular disease system being studied.

Effect of stressful stimulation on the incidence of streptozotocin-induced diabetes in mice.

In three experiments, groups of 8-18, 45-day-old male CD-1 mice were injected with a single dose of streptozotocin (STZ) and were followed for 12-31 weeks. Experimental groups were given periodic. light-shock stimulation beginning at various times after streptozotocin injection. Blood samples were taken biweekly from all mice. Blood glucose levels were attenuated over a 22 week period in mice that were stimulated during the first 72 hours after STZ injection. Incidence of insulin-dependent diabetes (blood glucose levels over 150 mg%) was also significantly reduced in stimulated mice. Progressively increasing correlations between sampling order and blood glucose levels, which were significant over the last 12 weeks of one experiment, indicated that blood glucose levels of caged, diabetic mice responded markedly to laboratory procedures.