The inpatient setting offers a rich environment for studying psychopathology, learning pharmacotherapy, and beginning skills in psychotherapy. Hospitalized patients are generally the most severely ill, suffering from psychosis, mania, and suicidal behaviors. Students and residents are able to participate in their treatment in a safe, controlled environment with direct, regular on-site supervision by an attending psychiatrist. They have an opportunity to interact with patients and the supervising attending free of the time constraints typical of other treatment settings, such as outpatient clinics or the emergency department. Given that inpatient-based clerkships have predominated in medical education since the late 19th century,¹ there is a hospital culture, including nursing and administrative staff, that encourages education in this setting. Attending psychiatrists serve as role models, especially because they are more involved in direct patient care than in the past, in part due to state and federal regulations.² Unlike many other educational settings, students and residents participate directly in the process of evaluation, diagnosis, and treatment of the patient under supervision. Because hospital stays are shorter, there is an emphasis on rapid, accurate diagnosis and treatment planning, as well as the need to establish relationships with severely ill patients.³ Students and residents participate as members of an interdisciplinary treatment team of health care professionals, including nurses, psychologists, social workers, occupational therapists and recreational therapists, an experience that may not be replicated elsewhere. In acute inpatient settings, families are typically involved, and their inclusion in treatment planning gives residents and medical students a chance to learn basic family assessment and intervention methods. In the inpatient setting, residents and medical students encounter problems that are unique to the discipline of psychiatry, such as the legal and ethical issues of involuntary commitment and treatment.

Perhaps the greatest strength of having residents train in the inpatient setting is that it encourages integration of their identities as physicians, even as they begin to assume their new roles as psychiatrists. As part of the Accreditation Council on Graduate Medical Education (ACGME)⁴ “Patient Care” competency, psychiatry residents are expected to perform physical and neurologic evaluations on their patients, and be able to integrate their findings to establish a clinical diagnosis. Depending on the training site, residents might be expected to assume complete management of their patient’s acute and chronic medical and neurologic problems, or work in conjunction with a medical consultant. At the very least, residents must be proficient in the diagnosis and treatment of organic mental disorders such as delirium and dementia, as well as pharmacologic and medical complications associated with other psychiatric illnesses. This early opportunity to integrate the roles of physician and psychiatrist is best done in the inpatient setting, and can be further enhanced in later rotations, such as consultation/liaison or emergency psychiatry.

Many factors have influenced the education of health care professionals, including psychiatrists. For example, the advent of managed care has had a tremendous impact on how and where clinical care is delivered, length of stay, treatment planning, and supervision of trainees. Inpatient admission is no longer an option for many patients, depending on their diagnosis and degree of lethality. Some insurance companies allow only patients with overt suicidal ideation or attempts to be admitted and many allow only brief stays. As a result, students and residents see the most severely ill patients with whom contact is usually brief due to shortened length of stays.⁵ Criteria for admission are now more stringent, and patient problems are generally narrower in scope and not likely to mirror the kinds of issues residents will face in actual practice settings.⁶ Patients must demonstrate severe pathology or symptoms, such as active suicidal ideation or acute psychosis, in order to be deemed appropriate for admission. In reality, most residents will practice in outpatient settings where patients are more likely to present with anxiety, mood, adjustment, or personality disorders. Most medical students will pursue training in specialties other than psychiatry, where patients present with more subtle psychiatric symptomatology which they may have difficulty recognizing if their training in psychiatry is limited to treating patients with psychopathology typical of those seen in inpatient settings. Because of shorter lengths of stay, medical students and residents may not have the opportunity to see their patients progress to the point of full recovery from their illnesses, or to develop relationships which enable them to focus on psychological factors influencing the patient’s illness.²

Because of the acute nature of the patients’ illnesses, treatment modalities in the inpatient setting are often limited. Medication, rather than psychotherapy, is the norm, and students get a distorted view of available psychiatric interventions. They may lose sight of the importance of the therapeutic alliance in treatment, and the value of psychotherapy, even for chronically ill patients. For medical students in particular, their impression of mental illness may be skewed such that they might perceive it in a negative light. Students have less of an opportunity to observe that even patients with severe illnesses can have productive and satisfying lives, a fact that is often lost because of short length of stays.

Faster turnover of patients and increased clinical caseloads for psychiatric attending physicians result in less time to educate students and residents.⁷ Requirements for documentation by attending physicians, as well as concerns about liability issues are additional factors which limit time spent with residents and students.⁸

Care of patients in the inpatient setting can be particularly stressful for students and residents, especially residents who are at the beginning of their training. Beginning residents from all specialties experience stressors unique to starting residency training. These include defining one’s role as a physician,
managing significant clinical demands with limited clinical experience, balancing training and personal needs, and forging a satisfactory relationship with supervisors and peers. For psychiatry residents in particular, there are unique obstacles to training, which are not experienced by residents from other specialties. The “beginning psychiatry training syndrome,” a typically transient and potentially valuable adaptive response, has been described and characterized as having temporary neurotic symptoms, psychosomatic disturbances, and symptomatic behavior.⁹ While the “syndrome” was first recognized at a time when psychotherapy was a mainstay in the treatment of psychiatric inpatients, the basic tenets are applicable even now regarding the emotional turmoil faced by beginning residents, and even medical students. Residents rotating on inpatient units usually have limited experience, yet are confronted by patients with the most severe illnesses. Residents must learn to recognize psychopathology, and assume significant responsibility for treatment of their patients, including psychological treatment. It is in the inpatient setting that residents first learn to process their own emotional response to patients and begin to define their role as a psychiatrist⁹ while maintaining their medical identity.

Emotional distress experienced by beginning psychiatry residents is part of normal professional development. Programs should monitor residents for stress, and can aid personal growth by incorporating professional development seminars, or experiential or T-groups into the curriculum. These may be especially useful to encourage beginning residents to forge relationships with their peer group and provide a forum to discuss the stresses associated with training in the inpatient setting.¹⁰

Fortunately, the inpatient psychiatric unit remains a vibrant entity for education of health care professionals. With some creativity and flexibility, many of the traditional methods of teaching in the inpatient setting remain valuable for training.