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This exclusive interview covers the importance of interaction and measurement in learning for patients and physicians. What makes interaction in a learning environment difficult for people? Can doctors "learn" to tolerate that not every patient likes them?
PSYCHED! A PSYCHIATRY PODCAST
with David Carreon, MD and Jessica A. Gold, MD, MS
An interview with Melissa Arbuckle, MD
Part 2 of 2
In the second part of our interview with Melissa Arbuckle, MD, she continues to discuss active learning methods. What makes interaction in a learning environment difficult for people? She then summarizes the use of quantitative measurement in psychiatric care, including in therapy. She details its effectiveness as a tool for self-monitoring in patients and whether it can predict relapse and to quantify a "baseline." She further mentions the use of the Working Alliance Inventory as not only an outcome measure but also a teaching tool. Can doctors learn to tolerate that not every patient likes them?
Dr. Arbuckle is Vice Chair for Education and Director of Resident Education in the department of psychiatry at Columbia University and the New York Psychiatric Institute,
Intro: Welcome to Psyched!, a podcast about psychiatry, that covers everything from the foundational to the cutting edge, from the popular to the weird. Thanks for tuning in.
Arbuckle: I remember the first grand rounds I did, where I decided I wasn't going to do a lecture, and I think it kind of shocked people in the audience, that no, we're actually going to do something different, and yet they walked away saying, "This was fun. Wow."
David Carreon: Tell that story. Where were you, who invited you, and did they know what was coming?
Arbuckle: The first time I did it, it was for a quality improvement curriculum that I teach, and the idea ... I asked everybody to come up with something they want to change in their own life and use that as a prompt for walking through the steps of quality improvement and how you set aims, how you measure outcomes.
For example, if you're going to set a goal for yourself ... My favorite goal that residents always say when I say, "Oh, let's set some goals," it's always read more. That translates into, probably nothing's going to happen. So if you think about it in the context of a quality improvement paradigm, then you're going to think about, what exactly am I going to read, how much am I going to read, what's my goal, what's my timeline for doing that, and it's far more likely to happen.
So we use that framework, I use that framework for teaching about quality improvement. So I did that exercise in a grand rounds and people played. I said, "You're going to pair up with a neighbor, and I want you to talk to your neighbor and report back," and it was fun.
David Carreon: Where was it? What was the room like? Tell us more about that picture.
Arbuckle: It was a traditional auditorium, so people were sitting in seats in an auditorium and kind of scattered about the room. I think the one thing that I sometimes have to do is get people to sit next to each other. So sometimes I say, "Okay, you're going to have to move, to sit next to somebody, because we're going to do something interactive." I think it takes people off guard. I think people are still a little uncomfortable about it. I did some interactive stuff, here at the APA, and a couple of people snuck out of the room rapidly.
Jessi Gold: I noticed that, too. Not in yours, but I was noticing that it was like as soon as the workshop part started, everyone was like ... some people just snuck out.
Jessi Gold: Yeah.
Jessi Gold: I wonder what ... I mean, I guess it's scary to have to actively do something. I don't know.
Arbuckle: Well, I think there's a piece of this thing that we're all afraid of being found out as a fraud, that we don't really know something, and perhaps, if you have to do something with someone else as part of an exercise, you're going to feel stupid or people are going to realize you're not the expert you're supposed to be. I think there's some performance anxiety that comes with that.
Jessi Gold: Probably scary for all levels of whatever for different reasons.
Arbuckle: Absolutely, yeah.
Jessi Gold: Yeah.
David Carreon: I mean, if somebody find out that we're not all omniscient, how are we going to be able to keep our jobs?
David Carreon: Another thing we wanted to talk to you about was the ... In psychiatry, I mean, medicine in general, but particularly psychiatry, we like to not measure things. We prefer to just sort of go along without measuring things and particularly in psychotherapy training. There's a lot of thought, particularly in psychodynamic or those sorts of approaches, that it really isn't science, and so you really can't measure things. I know that some of your work has involved trying to measure that and trying to improve that.
David Carreon: How would you even approach ... ? I mean, with all of the squishiness of the psychodynamic approach, how do you nail that down into something that is quantitative?
Arbuckle: Well, I think it depends on, with any treatment, what your goals are. Many patients that come to us for treatment have depression, anxiety, and there are standard rating scales available that you can use to measure those things, and to track them over time.
One of the classes I've taught is measurement based-care, and we literally talk about, how do you integrate this into a weekly treatment? Like, how often would you want to do measurement based care and how would you integrate it into a psychodynamic treatment, and it's not really any different than any other treatment. They fill out the scale at the beginning of the session, you look at the scale, you can a conversation about the scale, and then you can talk about their mother or whatever.
Jessi Gold: That's usually where I go, from scale to mother.
Jessi Gold: Yeah.
Arbuckle: But I think it's actually incredibly valuable to measure outcomes with patients and actually not just your own subjective impression about how a patient's doing. It provides you with more objective data about how a patient is progressing over time through treatment, but it's also incredibly tool for self monitoring for patients. They can see when they start to relapse, what are the first things on the scale that they struggle with?
One of my patients who has bipolar, we know it's sleep, so we're tracking that item really, really closely. One of my patients who has OCD ... I mean, I think the challenge was, for her, was, even though we both would have a subjective impression of how she was doing, the numbers were far more useful for the both of us. She would say, "Oh, ... " We would talk about, should we make a medication change, in terms of her treatment, and she'd say "No, I actually think this is probably my baseline. This is probably as good as I get." We pushed the medication, she got better. So for both of us, it was useful to say, "Oh, no, that wasn't your baseline.
This is your baseline. This is as good as you get, so let's keep this as our marker and our goal in your treatment."
I think no matter what kind of treatment you're doing, you want your patients to improve, and having real data for you and your patient to track that over time is helpful.
Jessi Gold: I know that also, there's ways to measure whether the patient likes the doctor, or feels like they're doing a good job, and you've been trying to integrate that some, as well.
David Carreon: Yeah, and that's challenging to our idea that we're always good doctors to all of our patients.
Arbuckle: Right. Right.
Jessi Gold: Right, or as a trainee, that we're never good doctors to any of our patients.
Arbuckle: Yeah, right. Yeah, so the Working Alliance Inventory is one particular tool where you can track how that's going, and I think that's particularly useful for trainees, in terms of ... And that's probably one of the most useful indicators of outcomes, is how good of an alliance, working alliance you have. I think that probably translates into treatment adherence and lots of positive contributions in terms of outcome. So having that kind of feedback early on could be really helpful. Yeah.
Jessi Gold: Also, could kind of kick your ego down a little bit.
Arbuckle: It could.
Jessi Gold: Yeah.
Arbuckle: So a couple of years ago, our residents did a quality improvement project, where they did patient feedback surveys. Patients filled out the surveys anonymously, and then residents got a graphic report back about how their feedback was, relative to their peers. But what was interesting is that some people got feedback from only one patient and some people got feedback from 20 patients, and actually the more positive feedback was usually from people who got feedback from lots of patients. So I think the challenge with that kind of data is, if you have one data point, not to overestimate the value of that data, whether it's positive or negative. For me, the take home point was really that the more data you have, the more accurate of a representation it's going to be.
And as a psychiatrist, I think we also ... you have to learn how to tolerate that every patient is not going to love you and make a connection with you, for all hosts of reasons. Maybe it's complicated, so we're talking about counter-transference, or maybe it's that they haven't come to terms with the illness they have and they're ambivalent about treatment altogether, so I think learning how to work with patients who are ambivalent about treatment is also a very useful skill to develop.
David Carreon: Well, we're coming toward the end of our time, and we like to ask a few rapid fire questions at the end.
David Carreon: And so we will ask you to keep your answers to one to two sentences, and this is very hard for psychiatrists and affiliated people-
David Carreon: ... so if we can try to keep it to two sentences, that'd be spectacular, so ...
David Carreon: First question is, what is something that psychiatry as a field can improve in, or an area that we, as a field, kind of get wrong?
Arbuckle: Wow. One or two sentences, huh?
Jessi Gold: If you want to talk longer, it's okay.
Arbuckle: No, it's okay.
Jessi Gold: Does that mean you have too much to say?
Arbuckle: No, I think that ... I wouldn't say that we get it wrong, I just think there's all these things on the horizon, that's coming down the pike, that we need to be paying attention to, so whether it's neuroscience training and the impact of neuroscience on our field, whether it's thinking about new healthcare delivery models and integrated care, or thinking about resource manager, these are all things we could do better and we need to do better.
Jessi Gold: What's your favorite book?
Arbuckle: Wow. I'm probably not ... I'm not a good person to ask that. You know what it is? It's Better.
Jessi Gold: By Atul Gawande?
Arbuckle: Yes. I love that book.
Jessi Gold: It sort of goes with quality improvement.
Arbuckle: It does. I quote his stuff in my presentations all the time.
Jessi Gold: Yeah.
David Carreon: What's advice you would give to a trainee?
Arbuckle: I think it would be about setting a framework for lifelong learning. I think they think ... you think, "Oh, I've got four years and I've got all this stuff to learn," and it's true, I think your learning during medical school and during residency is really exponential, in terms of all the things you learn, but there are going to be extraordinary advances in the field in your lifetime, and you need to be prepared to adapt to those changes. So I would recommend approaching learning in a way that really embraces a lifelong effort.
Jessi Gold: And who is a person, either living or dead, or fiction, non-fiction, whatever, who you consider a hero? Or someone you look up to?
Arbuckle: Wow. Well, there's a couple of different people that came to mind when you said that. I mean, I look up to my mother as a hero. She was a single mom for much of my childhood, raising four kids, and really struggled financially. I think that she was ... still maintained her compassion, and so I look up to her.
I would say I also really have been so fortunate to have Maria Oquendo as a mentor. She, just so selflessly, has been invested in my career and supporting me in a way that, I think ... She's just an amazing, busy person with all these other things she's doing, and the fact that she always set aside time to mentor me, I think that was incredibly special, so people like that.
David Carreon: You'd mentioned having fun is important. What's something fun that you've done, either as a child, or as an adult?
Jessi Gold: Just one thing.
Arbuckle: Just one fun thing ... Well, I have a seven-year old and an eight-year old, and ... I don't know, just spending time with them is super fun. My seven-year old just learned how to ride a bike a couple of weeks ago and seeing his excitement at figuring it out finally, that was really fun.
David Carreon: Great. Thank you for joining us.
Jessi Gold: Yeah, thank you.
Arbuckle: All right. Thanks. Bye.
David Carreon, MD, studied engineering at UCLA where he developed a love for science working on mechanically probing the rigidity of single cells. He completed his degree and moved on to medical school at Stanford. He took a leave of absence and moved to Kenya for a year to work as the medical lead for a Stanford-launched, anti-poverty startup called Nuru. Upon returning, he developed an interest in psychiatry and neuroscience, with a focus on cognitive control, an interest that has continued as he graduated medical school at Stanford and continued into psychiatry residency at Stanford. His research has involved multiple modalities, including designing one naturalistic project involving experience-sampling method approaches to understand self-control "in the wild." He has used TMS to try to modify inhibition control in an experimental fashion, and had looked at the role of executive function in mental illness via meta-analysis of neuroimaging studies. He is currently working on analyzing objective measures of cognition in post-war psychopathology and studying how these measures relate to subjective symptoms and neurological measurements. He also loves teaching, particularly neuroscience, and has spoken dozens of times to over 8,000 people.
Jessica ("Jessi") Gold, M.D., M.S. is a fourth-year resident and chief in Psychiatry at Stanford University. She was an undergraduate majoring in Anthropology at the University of Pennsylvania where she was a Benjamin Franklin Scholar and graduated Phi Beta Kappa in 2009. She also received a Masters in Science in Anthropology from Penn at the same time, using qualitative methods to study premedical education for her thesis work. She received her medical degree from the Yale University School of Medicine and graduated in 2014. While at Stanford, her primary interests are medical education, physician wellness, and the media portrayal of psychiatry as it relates to stigma. She enjoys both academic and popular press writing, frequently blogging for the Huffington Post and won the 2016 Psychiatric Times essay contest for her article titled "The Mirror." In her spare time, she spends time with her dog, her friends, playing bar trivia, and her growing extended family of 7 total nieces and nephews.