California Pacific Currents 2004
For David Alan Goldberg: A Personal Career Paralleled on a National Level
For years there has been a debate within the field of psychiatry, and David Goldberg, MD, Director, Residency Education, Department of Psychiatry at California Pacific Medical Center, has been at the center of it. The divergence of opinion springs from two different views of psychiatry: the biomedical model, which embraces stringent diagnostic criteria, a focus on addressing major mental illness, as well as the use of medication. By contrast, the biopsychosocial model, which relies heavily on contributions from psycho-therapy and pharmacotherapy.
These differing models create a dynamic within the field that is played out on a national level and within residency programs such as California Pacific’s.
Keeping Psychotherapy Integrated into the Teaching of Psychiatry
“The dominant theme in my professional life has been to keep psychotherapy integrated into psychiatry as the field has evolved towards a biomedical discipline,” says Dr. Goldberg. His belief is that the discipline of psychiatry will thrive and patients will receive the best care if it remains an integrated field. “So we must be familiar with not only specific diagnostic criteria and appropriate treatments, but we must also have exceptional communication skills and be able to treat our patients as whole people, not just a collection of symptoms.”
Leadership on a National Level
To ensure this balanced approach to teaching psychiatry residents, Dr. Goldberg has long been involved with the major psychiatric organizations in the United States, working with the American Association of Directors of Psychiatric Residency Training (AADPRT), where he has served as both Executive Director and now as President. The AADPRT is an organization of many of the educators and leaders of organized psychiatry in this country.
“I am also involved with four other national psychiatry groups: the American Psychiatric Association, the American Association of Chairs of Departments of Psychiatry, the American Board of Psychiatry and Neurology, and the Psychiatry Residency Review Committee (RRC). My intent is to develop better communication among these groups, especially about how we use new biomedical information to train the next generation of psychiatrists.”
And it appears his work has paid off. The last consensus statement issued by the Accreditation Council for Graduate Medical Education’s RRC for Psychiatry, the group that sets the requirements for all the discipline’s US residency programs gave psychotherapy a prominent role in the curriculum—the first time this has happened in many years.
The Challenge of Teaching Psychotherapy
“I was trained when psychiatry was heavily influenced by psychoanalysis. I loved it and felt that I had an ability to teach the practice of psychotherapy to others. Yet, I’ve always been fascinated by how difficult it is to learn.” From his early days at the University of Connecticut, Dr. Goldberg developed a number of strategies to teach psychotherapy, such as defining the core areas that needed to be learned and putting them into a logical sequence.
He has also done a great deal of work with videotaping. A videotape can make the educational and interpersonal issues clearer and more objective to the supervisor and the trainee. Videotaping also captures the therapeutic relationship between the resident and the patient. Even though it requires extra effort, video learning is being integrated into the psychiatry residency program at California Pacific. (Approval to tape is secured from all patients and the tapes are destroyed after they have been reviewed by the resident and supervisor.)
Residents Resonate with Treating the Whole Person
In the past several years, graduating medical students have shown an increased interest in the psychiatry residency at California Pacific. The four positions available every year now generate about 200 applications.
Of all of those who apply, 30 to 40 are interviewed by faculty and residents. Each applicant spends an entire day at California Pacific. The ideal candidate has a strong ability to relate to others, is intellectually oriented, analytical, and reflective.
The Nature and Culture of the Program
During their four years in the program, residents develop strong relationships with faculty mentors—one that goes well beyond didactic teaching. According to Arnaldo Moreno, MD, Chief Resident, “The standard for training here is one of professionalism, mutual respect among faculty and residents, intimacy in teaching, and diversity in training addressing various models of psychotherapeutic and psychopharmacologic approaches to patient care. The faculty’s genuine enthusiasm for teaching is contagious.”
Beyond mentoring is role modeling. Mentoring usually involves a transfer of information or skills, whereas role modeling evolves out of a person’s value system. As a role model, Dr. Goldberg wants to train physicians, by example, to experience the joy of connecting with another human being and helping them to get better and to grow. This applies to residents as well as to patients.
Psychiatry’s Contribution to Medicine
There is a very important role for psychiatry within all of medicine. This is an area known as consultation-liaison psychiatry, a subspecialty that focuses on psychiatric issues in medical and surgical patients. Such issues might include a schizophrenic patient who has had a heart attack; a diabetic patient who stops taking insulin due to depression; or a cancer patient and his family having difficulty adjusting to and coping with the diagnosis, treatment, and issues of death and dying.
“Consultation-liaison psychiatrists pride themselves on being able to combine medical, psychopharmacologic, and psychodynamic knowledge and interventions to best treat patients,” says Laura Duffy, MD, Staff Psychiatrist and psychiatric liaison to oncology. “I see consultation-liaison psychiatry as the ultimate biopsychosocial model which, by definition, requires psychiatrists, internists, and surgeons to see and treat the patient holistically.” The gold standard of medical care dictates an appreciation of the complex ways in which physical illness affects psychological health, and psychological illness affects physical health.
All California Pacific psychiatry residents have consultation-liaison rotations. In their second postgraduate year, they work with hospitalized medical/surgical patients, and in their fourth postgraduate year residents can select an elective that includes both inpatient and outpatient consultations to oncology patients and their families, as well as weekly, multidisciplinary psycho-oncology rounds.
Care for Those Who Need It Most
How can a residency program increase access to care for very ill patients who may fall outside the protection of our current medical system? To address this critical need, a rotation in community psychiatry has been introduced into the curriculum. Within the program, residents develop expertise in diagnostic techniques and the use of medications to treat severely ill patients. Because they work with a team of mental health professionals during this time, residents learn how to share the care of patients, hone leadership skills, and experience group dynamics.
The Best of Both Worlds
Dr. Goldberg and his associates are creating a program that brings together the best evidence about the effectiveness of diagnostic tools and psychopharmacology; the most recent research about the brain; and a strong foundation in medicine to provide excellent psychiatric care to California Pacific patients and the best of psychiatric education to the residents.
And, data support this assertion. Results from the major psychotherapy examination developed at Columbia University, which is administered annually to residents in approximately 70 programs, have just been reported. During the current academic year, psychiatry residents at California Pacific scored first in the nation on this standardized test.
“We need no longer perceive the mind and brain as separate, or look at medications and psychotherapy as mutually exclusive. They are part of the same discipline. To practice psychiatry today, residents must know the literature and understand the importance of evidence-based psychiatric treatment. The exceptional resident and psychiatrist also must be intuitive, self-reflective, and empathic; these are very different parts of us,” concludes Dr. Goldberg. This approach to psychiatry embraces the new but is also based on generations of experience.