Improving cultural competence of trainees has gained interest among medical educators, anticipating that this might reduce disparities in health care. Leading medical educators have added “the culture of disability” to this educational focus,27
albeit without specifically including persons with psychiatric disabilities. More research and experimentation is needed to develop new models for training medical students about communicating with patients with major mental illness. As Rubin and Zorumski32
suggest, these are exciting times for learning about mental health disorders. Some fears expressed by the students suggest that today's training approach may not effectively convey burgeoning scientific insight into major mental illness, as well as the current emphasis on positive outcomes and recovery for persons with these disorders. Medical school curricula typically separate courses to teach effective communication skills from those that teach medical knowledge and other clinical skills.37
Our interviews suggest the value of exploring approaches that combine communication skills training with more scientific teaching and clinical skills training about major mental illness. For example, providing greater scientific knowledge about the neurobiological bases for some psychiatric disorders alongside communication training could give students added insight and confidence in interacting with these patients. Such an integrated approach remains to be tested.
Students can learn much about psychiatry on nonpsychiatry rotations, but the focus group participants described explicitly negative messages that they received during clinical experiences, especially devaluing and diverting patients with mental health needs from the medical mainstream into psychiatric referral networks. On 1 level, that may give patients appropriate care. But it removes important opportunities for students to learn and treat the entire patient, not just the mental illness. We recommend that medical educators consider addressing these issues by educating learners at all levels—medical students, residents, and faculty.
Our medical student interviewees described discomfort or disinterest primarily among residents in other disciplines for addressing patients' psychiatric concerns. They said little about attitudes among attending physicians. However, residents' behaviors likely parallel their teachers' interests and behaviors. Educating attending physicians could possibly instill the skills to teach their trainees about communicating with persons with major mental illness. Some programs have taught communication skills to faculty,38–40
but we are unaware of training initiatives oriented specifically toward patients with major mental illness.
One interesting teaching initiative involved integrating communication training into a required family medicine clerkship.41
The program included both a student curriculum and faculty development. One novel component was “on site consultations” from specially trained behavioral scientists, observing preceptors, providing feedback, and paralleling the teaching process used with students. A similar program about communicating with patients with major mental illness could help facilitate the transfer of skills from attendings to trainees.
All physicians involved in direct patient care need the language, communication skills, and confidence to communicate effectively with persons with major mental illness. Our interviews suggest that the challenge of developing superb communication skills with these patients extends beyond training medical students. Larger cultural contexts in which faculty operate powerfully shape the values and attitudes of learners. Medical educators should consider both faculty and student needs and behaviors in designing communication skills improvement programs.