TEACHING EXPERIENCES IN GENERAL HOSPITALS* JOHN ROMANO, M.D., AND GEORGE L. ENGEL, M.D.

From the Departments of Psychiatry and Medicine, Universio of Rochester, School of Medicine and Dentistry, and the Strong Memorial Hospital,

Rochester, New ,York

URING the past eight years we have had the opportunity of working D intimately with the medical service of three university general hospi, tals. In this period of time one or the other of us has been associated full-time as a member of the department of medicine in each of these hospitals. In the Peter Bent Brigham Hospital in Boston the appointmentq were exclusively in medicine. In the Cincinnati General Hospital and in the Strong Memorial Hospital one of us has held, and holds, joint appointments in medicine and in psychiatry. This arrangement enabled us to accumulate certain experi- ences in teaching and led us to a particular concept of disease.

We have been impressed with the fact that the scope of our clinical ex- perience differs from that obtained in the traditional training of the career psychiatrist. Before recounting the nature of this clinical experience and our interpretations of its use, we feel it may be of value to relate the manner in which we have worked.

In each experience we have accepted the assignment of total medical responsibility for all of the patients on a medical ward or unit of the hospital. We were, therefore, exposed to a large and unselected group of sick people. We saw a great number of patients who presented psychological problems which had come to the attention of the medical student and house officer, but an even greater group in which at first glance there appeared to be no apparent or obvious psychological issues causing or complicating their ill- nesses. We should like to emphasize this point, a s the intimacy of OW

relationship within the body of the medical service enabled us to gain a broader experience than one usually afforded the psychiatric consultant who is asked from time to time to examine a patient on such a service who presents a specific problem.

Teaching methods were of two types. Bedside interviews were conducted with the medical student or house officer, or the patient was assigned to a medical student, house officer, or fellow for study. In the former instance a discussion was held with the student or house officer following the interview. In the latter, the student, house officer, or fellow would present the data to one of us for discussion and interpretation, and the patient was seen and interviewed by the other of us a t this time. In either instance, when it Was necessary to obtain additional data through the special skills of the social worker, psychologist, or medical specialist in any field, it was done.

* Presented a t the 1947 Annual Meeting in a Round Table discussion of “Psychiatry in Postgraduate

1 R. A. Spitz. The Smiiing Response: A Contribution to the Ontogenesis of Social Relations. Gene’‘ and Undergraduate Medical Education.”‘

Psychol. blonogs., 34: 57-125, 1946.

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Early, we found that we were dealing with a very considerable number of patients of the following types:

1. Those with continued and a t times intractable pain syndromes in- &ding the common complaints of headache, backache, bellyache, in which evidences of structural impairment were minimal or disparate. These patients usually had been subjected to repetitive diagnostic studies, and often to multiple surgical explorations.

2. Patients with disparate convalescent patterns, in which recovery from injury, illness and surgical intervention was unduly delayed.

3. Patients with non-specific symptoms of fatigue, restlessness, irritabil- ity, depression, insomnia, anorexia, constipation. 4. Those with more clearly delineated patterns of gastroduodenal ulcer,

bronchial asthma, hypertension, colitis, etc. 5 . Patients in whom psychological factors played a role in the develop-

ment, course, or management of organic disease, or in whom organic disease or surgery led to unexpected psychological complications.

6. Those with evidence of disturbed cerebral metabolism in the form of deliria, or with irreversible structural brain disease.

7. Aging and aged patients without evidence of dementia, who were having difficulty in adjusting to organic disease.

8. Patients with traditional neuroses, with or without organic diseases. 9. Least common in our experience were patients with functional psy-

choses, character disorders, and addictions. The back-drop to all of this' consisted of our observations of the psycho-

logical experiences of patients with acute and chronic illnesses and with irreversible structural disability during the various phases of illness, includ- ing convalescence; and in the parallel observations of the experiences of medical students and house officers who, for the most part, were attempting valiantly to understand the behavior of their patients. It soon became clear that the difficulties in teaching-and they are many and formidable-lay less in ignorance of certain factual data of syndromes and disease entities than in the lack of a more comprehensive frame of reference or conceptual scheme of disease with which the student had heretofore been unfamiliar. This con- ceptual scheme is one in which psychologic and social factors exist or coexist with more impersonal biologic factors, eventually to cause, provoke, or otherwise modify variations in the total human biologic behavior.

This observation, seemingly banal to most of us, we believe to be of the utmost importance. Before a student can aggregate specific data to apply toward cause and effect relationships of human behavior, it will be necessary for him to acquire the proper frame of reference onto which these data may be arranged in a logical and systematic manner. For this to take place will mean a very considerable change in the structure of the undergraduate medical curriculum, and perhaps, in the last analysis, in the teaching of

604 TEACHING EXPERIENCES IN GENERAL HOSPITALS

fundamental concepts of biology. For example, it is apparent to anyone who attempts to teach medical students that the concept of disease is in urgent need of definition. To many it consists of a static compilation of gross be- havioral changes, often with little awareness of the dynamic and constantly changing interaction between stimulus and host, afforded by the innumer- able physiological, psychological, and social adaptive devices at the disposal of the human organism.

We have found that the concept of “homeostasis” has enabled us to clarify our thinking in this regard. This term, homeostasis, was originally in- troduced by Cannon to describe a physiological state of interaction resulting in the maintenance of equilibrium in the whole organism. The concept has been expanded by its author, and at the present time is also widely applied to describe psychological interaction taking place in the process of maintain- ing psychological equilibrium. Essentially this is a restatement of Fechner’s Stabilitatsprinzip, elaborated by Freud under the name of the “pain-pleasure principle.” Later Freud developed his concept further to include phylogeny as well as ontogeny, and extended it by introducing that modification of the pain-pleasure principle which he called the “reality” principle. In essence, the concept is that of a regulating principle which serves to maintain a given state of equilibrium and to reestablish it when disturbed. While our thoughts of the concept of disease are far from being definitive, we have found the use of the constancy principle, inherent in all of the above, to be of pragmatic value in explaining health and disease. In a broad sense health may be de- fined as the maintenance of equilibrium between the impact of stimuli on the biological organism and the adaptive devices utilized by the organism to meet these stimuli. Literally, disease means “lack of ease” or “trouble.” One may be able to interpret it, then, in its simplest form as the result of a dis- turbance in the equilibrium.

The equilibrium may be upset in three ways. The suddenness or magnitude of the noxious stimuli may temporarily overwhelm relatively normal adaptive devices. Second, seemingly innocuous stimuli may cause a dis- turbance when the adaptive devices are undeveloped or weakened, and finally, combinations of the first two means may occur to produce a dis- turbance of equilibrium. I t is thus possible to point out to the student how the constancy principle may help to understand the organism’s reactions to widely differing types of stimuli; e.g., deprivation of oxygen or the loss of a loved person; to point out the nature of the adaptive devices to meet these stimuli, changes of depth and the rate of breathing on the one hand, and the healing process of acute grief on the other; and finally, the possible reasons for success or failure of the adaptive devices to reestablish the state of equilibrium. In our opinion comprehensive medicine can be taught only when the student is equipped with biologic concepts broad enough to in- terpret intelligently the complex and dynamic interaction of forces which take place in the human organism in both health and disease.