PSYCHED! A PSYCHIATRY PODCAST
with David Carreon, MD and Jessica A. Gold, MD, MS
An interview with Melissa Arbuckle, MD
Part 1 of 2
In the first part of this interview, Dr. Melissa Arbuckle, Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute, discusses neuroscience education for psychiatrists and the general public. She focuses on an innovative teaching curriculum that she co-developed called the National Neuroscience Curriculum Initiative and the ways in which this curriculum makes neuroscience accessible, clinically relevant, and interesting.
She describes how understanding and teaching neuroscience can actually reduce stigma towards psychiatric illness (eg, addiction) for patients and decrease countertransference in psychiatrists. Additionally, she broadens the scope to discuss active teaching methods and adult learning principles in general. In rejecting lecture as a good teaching method, she also discusses what is so "scary" about teaching and "making" participants interact with each other.
David Carreon: Hey, everybody. This is David Carreon.
Jessi Gold: This is Jessi Gold.
David Carreon: And this is Psyched! Today we have Melissa Arbuckle with us, the Co-director of Resident Education in the Department of Psychiatry at Columbia and the New York State Psychiatric Institute. She went to medical school at the University of Oklahoma and did a residency at Columbia. She served as a New York State Office of Mental Health policy scholar, 2009 to 2012, exploring the implementation of standardized patient assessments and measurement based care in the clinical practice of residents in training. She directs the quality improvement curriculum for the residency training program. Thank you for joining us.
Arbuckle: My pleasure.
Jessi Gold: You have a correction?
Jessi Gold: What is it? It's okay.
Arbuckle: I'm now the Director of Residency Training and I'm the Vice Chair for Education, so, yeah, that hasn't been updated.
Jessi Gold: So a promotion?
Arbuckle: Yes, a promotion.
Jessi Gold: That's always good.
David Carreon: Congratulations.
Arbuckle: Thank you.
Jessi Gold: Congratulations.
David Carreon: So, well, thank you for joining us, and we've got a lot of ... I'm excited to talk to you about a number of things, but particularly the role of neuroscience in the psychiatry curriculum.
David Carreon: What are your thoughts on why that's a good idea or not?
Arbuckle: Well, I think our knowledge, in terms of neuroscience and its relevance to the clinical practice of psychiatry, is increasing daily. The research in neuroscience and psychiatry is really exploding, and if that research is going to reach patients, it's going to require a clinician workforce that understands that work and can speak that kind of language.
David Carreon: So, say more about what are some of the ways that neuroscience can be integrated into a curriculum. I mean, what would that look like?
Arbuckle: In terms of medical training?
David Carreon: Yeah.
Arbuckle: I think that, as part of the National Neuroscience Curriculum Initiative, we've been developing teaching resources, and that started in terms of thinking about how we teach neuroscience in the classroom, and particularly how we make sure that neuroscience for a medical audience feels clinically relevant, that it's taught in a way that capitalizes on adult learning, and that it's experience near to trainees and their role with patients.
When we first started, we were really thinking about how to do that in the classroom, but most of your training is in clinical settings, so more recently we've moved towards developing short videos, in terms of teaching core neuroscience topics, that can be used in clinical settings with both the teacher and the trainee together.
I think we have this model for education where the teacher is supposed to be the expert, teaching something to a student, and for neuroscience, the field is exploding and most clinicians are not neuroscience experts and feel uncomfortable teaching. So we've developed really short educational videos that teachers or faculty and trainees can watch together and learn together. So it's really a different way of teaching.
David Carreon: Yeah, no, I think that's definitely ... The old model, or at least the traditional model of expert trainee is ... that kind of turns it on its head. I mean, are these videos that are available online or what's-
David Carreon: What is the project?
Arbuckle: Yes. In 2014, I joined with Mike Travis and David Ross to develop the National Neuroscience Curriculum Initiative, and in that project we put all of these open resource videos, papers online. Anyone can log in, create a login to access the materials, and the idea was to really disseminate neuroscience education in a way that was accessible and clinically relevant and all of those things.
Jessi Gold: Do you feel like neuroscience has the potential for people that are in psychiatry to feel like it's boring?
Arbuckle: In terms of the way it's currently taught?
Jessi Gold: Yeah.
Arbuckle: Yeah, so I think that's one of the major challenges in teaching neuroscience, is that the way it has been historically taught is, in our traditional models, that the expert will come in and do a lecture, because scientists are used to teaching to a scientific community, and that's usually ... that dissemination is usually a PowerPoint slide set. So they come in with their talk from their latest meeting, ready to engage medical students or residents, and I think they miss the mark a lot of times.
They don't really realize the lack of foundational knowledge that medical trainees have, so they make a lot of assumptions about what clinical trainees know and don't know, and within a few minutes, trainees are often lost and it doesn't feel clinically relevant. It's about their latest rat study and they don't make that effort to say, "This is how this matters to the patient that's going to be in front of you tomorrow." I think that's been a huge challenge and partly why neuroscience in education has not been so great, up until now.
David Carreon: Is this something that ... ? You said these modules are online, is this ... ? Some of our listeners are psychiatrists, but some of them are not. Some of them might be patients or family members. Is this something that you're hoping everybody can use?
Arbuckle: Absolutely. When we first started, we had this idea that we would create different modules for different learners. So we would have some basic stuff that was more for the lay public, we'd have some intermediate stuff that might be for medical students and residents, and then perhaps expert level content. What we found is, really, everyone's kind of at the lay public level, that we don't know anything about neuroscience, and so all of these resources are incredibly accessible to anybody.
One of our modules that I think is particularly great is called Talking Pathways to Patients, and in these sessions a ... in one, it's a trainee, in another it's a faculty member, role play what they would say to a patient. One is about the neuroscience underlying addiction, and the idea is that they're demonstrating what you could say to a patient, but there's no reason why those videos couldn't be directly useful to the patient population that they're targeting.
David Carreon: Now, have you gotten any feedback from non-doctors or non-trainees about the modules? Do you know of anybody who's used these or who's gone through these modules, that's not a medical affiliate?
Arbuckle: So, I don't know ... Our main outcome measure we've been looking so far is just uptake and we don't really know who's using the modules so far, but certainly the people who have been using them have been incredibly enthusiastic. We also have several resources that we've shared over Facebook and when we're getting the highest hits, in terms of the things we disseminate, my suspicion is that it's the lay public that's really doing the uptake, as opposed to faculty and trainees.
I think it's a huge potential target for the work we're doing, and a lot of interest ... I think patients really want to understand what's going on, and to have a medical model that explains addiction in the context of the reward circuit, I think, can really decrease stigma, self stigma, and can be a really powerful treatment tool.
Jessi Gold: It probably does patients a bit of a disservice to really, really dumb it down because we don't understand it ourselves.
Arbuckle: That's right.
Jessi Gold: Yeah.
Jessi Gold: Wow.
David Carreon: With that, the stigma piece, from one perspective they could say, well, the dopamine sort of ... there's too much dopamine, simplistic 30-year old story. How would the neuroscience version of that, or the circuit based model of the past, you know, updating things, how could that reduce stigma even further than what's already been done, say with the more simplistic dopamine model?
Arbuckle: Well, the current session that we have posted online really talks about the neurocircuit and different areas of the brain, and with happens with a heroin addiction. So what is the normal reward circuit, and then what happens and how heroin can hijack that circuit, and how different areas of the brain are upregulated and different control mechanisms are downregulated. I think that it explains why patients can find themselves with a lack of control over something that they feel they should be able to control. I think having that perspective can take away some of the self blame, the guilt that patients experience. It also provides a really robust model for thinking about how we can target each area of that circuit with different treatments, whether it's medication or psychotherapy. I think it's a model that brings together a lot of different treatment modalities in a unifying model.
David Carreon: This is sort of a story that's more compelling, say, then a more simplistic biological version from the past, or a moralizing version from maybe the present.
Arbuckle: Yeah. I think it's also helpful for physicians, in terms of counter-transference, that when you're working with patient populations where there is a lot of relapse, it can be incredibly frustrating, and particularly when it's associated with ineffective behaviors. So for clinicians to reframe what's happening with your patients, that your patient who is, quote, unquote, "drug seeking" isn't in your office to torture you, but there's something going on at a biological basis in their brain, I think it just reframes your own empathy for that person and could be really helpful in that way, as well.
David Carreon: So there's a few ways to approach the counter-transference relationship and I think that, certainly, there's been some evidence to suggest that a neuroscience understanding, or a biological understanding, can sometimes increase stigma, that if you say, "I am this way because of stuff that happened to me in childhood," rather than, "I am this way because I have a brain disorder," there are some studies suggesting that there's even more stigma ...
Arbuckle: Right. I think it's important to keep it balanced so that, you know, neuroscience isn't just about underlying genetics, but epigenetic changes, so it really is ... When we say that neuroscience and biology is a part of that, experience shapes biology, so these are not one or other.
The other thing is that there's been some really interesting research looking at stigma and what shapes stigma, and some of the data suggests that if you pair psychiatric illness with a message of hope that there is treatment available, that that can be incredibly powerful in decreasing stigma. I think that when we start talking about these biological models, one of the things we've done in the sessions we've developed is really talk about how that biological perspective can inform treatment, and so pairing it with this message of hope and there's something we can do about it, and this how this transforms into treatment options for you and how we can frame treatment options within the context of the neuroscience, I think that could be very powerful.
David Carreon: So sort of trying to take the fatalism out of biology.
Arbuckle: Exactly. Exactly. Yeah.
Jessi Gold: I noticed, also, that you've done some work with teaching trainees how to explain drugs and the side effects of medications to patients as well, and I'd assume that this falls into the same realm for you.
Arbuckle: I think the things that they have in common is really thinking about active teaching approaches. I think medical education, in general ... I probably unfairly targeted the neuroscientists, coming in with their slide deck. This is actually what all of our professors do, right. They come in ... for psychopharmacology, let's say, they come in with their slide deck and they're going to run through, "These are the drugs, these are the starting doses, these are the side effects," and I can't imagine a more boring way to spend an hour, than having someone lecture on something I could look up in a book.
So for teaching, in terms of talking to patients about psychopharm, it's really about using active teaching modules. So residents role play talking to each other, one playing the role of the physician, one playing the role of the patient, and saying, literally, what would you say to a patient when you're going to start a certain medication, in terms of informed consent? What do they need to know about the starting doses, the side effects? How do you talk about really scary side effects in a way that's not going to contribute to medication non-compliance? And that just transforms what was previously a passive learning experience into something incredibly active and incredibly applicable to clinical work. I think that's what's in common, is really thinking about different ways of teaching.
David Carreon: Yeah, and I guess that gets into something that goes far beyond psychiatry, but you've mentioned a few times adult learning and ways that we, just as people, as human beings, remember things better. What are some principles that you've come to appreciate from your work in adult education?
Arbuckle: Well, I think that learners have to be actively manipulating information. So being a passive recipient and not doing anything to actively manipulate information ... The data suggests that if you're sitting in an hour-long lecture, you might remember 5 to 10 minutes' worth of content. When we're pressed to teach so many thing in training, we can't afford to have wasted time, so it's really about getting trainees thinking and coming up with solutions themselves. If you can come up with a solution yourself rather than someone telling you the answer, that's more likely to stick. If you can learn something in an experiential way, that's more likely to stick.
For example, in the neuroscience education, one of the modules is on the fear circuit, and prior to a conversation about the fear circuit, and how we understand the fear circuit, everyone watches a short horror film. Once you've had your own fear circuit activated then talking about what just happened in your brain, that's a very different experience than passively having someone lecture to you.
Jessi Gold: And probably more fun.
Arbuckle: Well, that's the thing. I don't know what happened in education, that somewhere between kindergarten and medical education we decided that learning shouldn't be fun. I'm a big fan of learning being fun, so as part of the NNCI we have trainees make brains out of play dough and it's fun. It's really fun.
David Carreon: So let me get this straight, you have people with advanced degrees making play dough brains?
Jessi Gold: I think we did that.
Arbuckle: You did it. I'm sure you did.
David Carreon: Yeah, it was spectacular.
Arbuckle: But, you know, it's funny, because I originally thought ... My anxiety about doing play dough brain and having people make a brain out of play dough was not that they would think it was too hokey and be unwilling to do it, but they just wouldn't know how to do it. When Dave Ross suggested we were going to do this, and we were going to create brains out of play dough, I said, "Well, I wouldn't even know how to start." He said, "No, no. We're going to make a video. We're going to show people how to make a brain out of play dough," and it was not only fun, it was incredibly useful.
Usually, when you're sitting in a grand rounds, you're looking at some two dimensional image and you're trying to orient yourself, "Okay, they're pointing at something. What is that?" And actually, in this exercise, I discovered I'm a kinetic learner. I really learned in this way of manipulating objects in space was really a useful learning tool for me, so ...
Jessi Gold: I think it's interesting, too, you mentioned kindergarten to college, like if you never tried any of these methods of learning, you wouldn't know that you were a kinetic learner, right?
Jessi Gold: But you just kind of go with whatever the people do.
Arbuckle: Yeah, right. Right.
Jessi Gold: Yeah.
David Carreon: So you're saying that most people are not dry, boring slides from a PowerPoint deck that are presented monotone learners?
Arbuckle: That's right. That's right, most people are not. That's probably the least effective way to teach, and yet we do it everywhere.