Student Reflections on the Paucity of Psychotherapy Education in U.S. Medical Schools

Psychotherapy is an important component of treatment for patients with psychiatric conditions. Furthermore, learning to use psychotherapeutic techniques to conduct patient interviews can improve rapport, promote empathy, and increase effective communication (1, 2). From our point of view as medical students, U.S. psychotherapy education is inadequate and is an area that needs improvement in medical schools nationwide.

Clinical skills curricula for undergraduate medical education outlined by the Association of American Medical Colleges (AAMC) include communication skill competencies delivered through longitudinal, learner- and relationship-centered training. According to these guidelines, medical students should achieve a minimum proficiency in communication skills before beginning clinical clerkships. Students should then advance and continuously refine these skills throughout their clinical experiences (3). A frequently cited and well-regarded approach to the medical interview, the Four Habits Model (4), places demonstration of empathy at the core of efficacious communication skills. However, most complaints and lawsuits against physicians cite poor communication as a main cause (1), and studies (1, 2, 5) have suggested a decline in empathy as clinical training progresses. Teaching psychotherapeutic skills represents a possible solution.

As medical students, our psychiatric education mostly covers diagnostic criteria, pharmacotherapy indications, and mechanisms of action. Information on psychotherapeutic modalities, however, is limited; even basic definitions of different psychotherapy techniques are often not well understood by students. However, the Association of Directors of Medical Student Education in Psychiatry advocates for a basic understanding of psychotherapy, including an ability to “recommend specific psychotherapy for designated patients” (6), to be a fundamental goal of medical students. This inconsistency is commonly attributed to the limited duration of psychiatry rotations and limited faculty expertise in multiple psychotherapeutic modalities (7). Meanwhile, in the United Kingdom, at the University College London School of Medicine, psychodynamic therapy teaching methods have been shown to be effective in increasing students’ knowledge of the doctor-patient relationship and in promoting student recruitment into psychiatry (1). Furthermore, at the University Medical Center Hamburg-Eppendorf in Germany, the early implementation of a new communication training program (2) has been shown to be particularly useful in enabling students to achieve specialized competence in communication skills.

Educating physicians about evidence-supported psychotherapy treatments can contribute to patients learning about, seeking, and receiving psychotherapy when indicated. Most patients with common mental disorders, such as depression, are treated by general practitioners rather than by psychiatrists, and most of these patients prefer psychotherapy over pharmacotherapy (8). Furthermore, the World Health Organization (9) has recognized a multitude of psychotherapeutic modalities as being effective in treating common mental disorders and has recommended the utilization of cognitive-behavioral and interpersonal therapies, among other interventions. A meta-analysis (8) has demonstrated no significant differences in efficacy between psychotherapy and pharmacotherapy, and evidence suggests that combined treatment is likely better than either modality alone. Likewise, a systematic review of neuroimaging studies (10) has shown preliminary evidence that, with some but not all psychiatric disorders, patients receiving psychotherapy manifest functional brain changes associated with the progress and outcome of psychotherapy that are comparable to those associated with medication use. Depending on the disorder under investigation, psychotherapy was shown (10) to result in normalization of abnormal patterns of brain activity, recruitment of additional areas of the brain that did not show altered activation prior to treatment, or a combination of these two findings.