Undergraduate training in Psychiatry: World perspective

HISTORICAL DEVELOPMENT OF MENTAL HEALTH SERVICES During the last three centuries, there has been major shifts in the way mentally ill are viewed and cared for all over the world. The changes during the last 50 years are most significant. From a situation of considering the “mad” as “bad” and incarceration in jails and asylums, there is now recognition of the human rights of the mentally ill. From jails and asylums, the care of the mentally ill persons has moved to the community. Another important development is the care providers. Current approach to care in the community includes, besides psychiatrists, other mental-health professionals, primary-care doctors, family members, volunteers and the ill persons. The driving forces towards these changes have been many: the recognition of the wide range of mental disorders, the high prevalence of mental disorders in the community, the availability of a variety of interventions (pharmacological and nonpharmacological), the demonstration of the effectiveness. HUMAN RESOURCES FOR HEALTH CARE There is an international focus on human resources for health care. The theme of the World Health Report 2006 (WHR 2006) was Working Together for Health. The WHR 2006 begins with the following observation: “In this decade of the 21st century, immense advances in human well-being coexist with extreme deprivation. In global health we are witnessing the benefits of new medicines and technologies. But there are unprecedented reversals. Life expectancies have collapsed in some of the poorest countries to half the level of the richest - attributable to the ravages of HIV/AIDS in parts of sub-Saharan Africa and to more than a dozen “failed states”. These setbacks have been accompanied by growing fears, in rich and poor countries alike, of new infectious threats such as SARS and avian influenza and “hidden” behavioural conditions such as mental disorders (emphasis added) and domestic violence.”(xv) (emphasis added). Further, the report states The ultimate goal of health workforce strategies is a delivery system that can guarantee universal access to health care and social protection to all citizens in every country. There is no global blueprint that describes how to get there - each nation must devise its own plan. Effective workforce strategies must be matched to a country's unique situation and based on social consensus (emphasis added). (p.119) The human resources for mental health care are grossly inadequate in the developing countries, as presented by the WHO Atlas document in 2005. In the Indian context, the development of appropriate human resources for health in general is receiving serious attention. For example, the setting up of the Public Health Foundation of India in 2006 is a good example of this concern. Both authors come from a background of community mental health and experience of training and working with primary health-care doctors. The effort is to present the “world” perspective (from the World Health Report, the World Psychiatric Association (WPA) guidelines, experiences of different countries) and identify some issues relevant to undergraduate education in India. World Health Report 2001 The World Health Report 2001 makes 10 overall recommendations. The first of this is “Provide treatment in primary care.” The management and treatment of mental disorders in primary care is a fundamental step which enables the largest number of people to get easier and faster access to services. It is to be recognized that many are already seeking help at this level. This not only gives better care but also cuts wastage resulting from unnecessary investigations and inappropriate and nonspecific treatments. For this to happen, however, general health personnel need to be trained in the essential skills of mental health care. Such training ensures the best use of the available knowledge for the largest number of people and makes possible the immediate application of interventions. Mental health should therefore be included in training curricula, with refresher course to improve the effectiveness of the management of mental disorders in general health services. Integration of mental health care into general health services, particularly at the primary health-care level, has many advantages. These include less stigmatization of patients and staff, as mental and behavioral disorders are being seen and managed alongside physical health problems; improved screening and treatment, in particular, and improved detection rates for patients presenting with vague somatic complaints which are related to mental and behavioral disorders; the potential for improved treatment of the physical problems of those suffering from mental illness and vice versa; and better treatment of mental aspects associated with “physical” problems. For the administrator, advantages include a shared infrastructure leading to cost-efficiency savings, the potential to provide universal coverage of mental health care and the use of community resources which can partly offset the limited availability of mental health personnel. The specific ways in which mental health should be integrated into general health care will, to a great extent, depend on the current function and status of primary-, secondary- and tertiary-care levels within countries' health systems. For integration to be successful, policy makers need to consider the following: general health staff must have the knowledge, skills and motivation to treat and manage patients suffering from mental disorders; there need to be sufficient numbers of staff with the knowledge and authority to prescribe psychotropic drugs at primary and secondary levels; basic psychotropic drugs must be available at primary and secondary levels; mental health specialists are required to provide support to, and monitor, general health-care personnel; effective referral links between primary, secondary and tertiary levels of care need to be in place; funds must be redistributed from tertiary to secondary and primary levels of care or new funds must be made available; and recoding systems need to be set up to allow for continuous monitoring, evaluation and updating of integrated activities. WORLD PSYCHIATRIC ASSOCIATION RECOMMENDATIONS In 1998, the WPA, along with the World Federation of Medical Education (WFME) through a core curriculum committee, developed detailed guidelines for the “Core Curriculum in Psychiatry for Medical Students.” One of the authors (RSM) was a member of the core curriculum committee. The recommendations present the world view of the subject. The main recommendations are given below. (The full report is available from the WPA website.) That Psychiatry should occupy a major part in the medical curriculum is now generally agreed. There are three reasons for this agreement. First, the general approach of Psychiatry which stresses the unity of body and mind is important in the whole of medical practice. Secondly, skills that are learned in Psychiatry are important for all doctors: for example, the ability to form a good relationship with a patient, to assess the mental state and to impart distressing information. Thirdly, psychiatric problems are common among patients seen by doctors working in all branches of Medicine: for example, it is known that among outpatients attending specialist clinics, about 15% of those given a diagnosis have an associated psychiatric disorder; and an average of 20-30% of those given no medical diagnosis have a psychiatric disorder. Psychiatric disorders are even more frequent among patients attending general practice. Therefore, all future doctors must know about these psychiatric problems, not only because they are common but also because their management involves much medical time and resources and gives rise to many serious incidents. THE PROPOSED CURRICULUM The core component in Psychiatry in the curriculum described in the WPA/WFME Report is the minimum that is required by medical students who, after qualification, will enter further training whether they are to work as specialists or in primary care. In many countries, doctors who have chosen a career in primary care (general practice) receive a further period of training after graduation; and in most of these countries, this training extends their psychiatric skills. In countries with no formal training for primary care doctors (general practitioners), the teaching in Psychiatry described in this report needs to be supplemented by a module containing the additional material that is essential for management of the psychiatric morbidity encountered in general practice. This module will need to be developed locally to take account of the special circumstances of practice in the country. The report describes the minimum requirements in Psychiatry for medical students who will enter further training, whether they are to work as specialists or in primary care. ATTITUDE OBJECTIVES Since most students will not enter Psychiatry, the acquisition of appropriate attitudes is of primary importance. It is important that the objective of imparting these attitudes is in the teacher's mind throughout his/her interaction with students. Most of the attitudes to be acquired while learning Psychiatry do not differ from those needed to practice the rest of Medicine. The extent to which these attitudes are emphasized to students in the Psychiatry program, rather than during the periods for other subjects, will vary from one medical school to another. However, each school should have a clear plan that ensures that the necessary attitudes have been acquired by the time the students graduate. It is important that students develop appropriate attitudes towards Psychiatry as a medical discipline. These attitudes will be encouraged, particularly during the teaching of Psychiatry, but it is important that they are not negated during the teaching of other subjects. It is important that attitudes are not merely expressed verbally by students but are also internalized, directing how students respond to patients and their colleagues. Each of the attitudes listed below should be translated into corresponding action. Attitudes concerned with medical practice generally Students should recognize that the profession of Medicine requires lifelong learning and show capacity for critical thinking and constructive self-criticism; be able to tolerate uncertainty and be open-minded to the views of others and be able to work constructively with other health professionals. Attitudes towards patients and their families Students should respect patients and understand their feelings; recognize the necessity of good doctor-patient relationships; appreciate the value of the developmental approach to clinical problems, emphasizing the stages of the life cycle and longitudinal perspective of illness; recognize the importance of the family and the wider environment of the patient and attitudes towards Psychiatry as a medical discipline Students should recognize the value of Psychiatry as a medical discipline; integrate humanistic, scientific and technological aspects of knowledge of Psychiatry and recognize the importance of the promotion of mental health and the prevention of psychiatric disorders. KNOWLEDGE OBJECTIVES The knowledge objectives of Psychiatry include psychiatric symptoms and syndromes; psychological aspects of medical disorders (“psychological medicine”); and psychosocial issues, including stigma. Psychiatric symptoms and syndromes and their treatment are to be taught and learned in the context of an integrated biological, psychological and social approach. Knowledge objectives can be formulated in broad terms or as a detailed curriculum. A detailed list may be important not only to guide teachers and students but also to indicate to the deans and curriculum committees of the medical school, the substantial factual basis of Psychiatry and the resources needed to teach this. Whatever level of detail is chosen concerning each individual disorder, collectively these should provide opportunities to (a) illustrate the approach to etiology in psychiatry; (ii) discuss attitude objectives and “teaching of skills” objectives; (iii) provide instruction concerning action that should be taken. SKILLS OBJECTIVES The skills required by medical students range from those with which they need only be familiar (in the sense of being aware that they are practiced by others, e.g., dynamic psychotherapy) to those skills which students are expected to utilize competently themselves. Many of the skills students learn in Psychiatry overlap with those learnt in the other branches of Medicine. The stage in the curriculum at which the various skills should be learnt is a matter for the curriculum committee of the medical school to decide. Skills to be acquired include the following: Doctor-patient interpersonal skills include the skills of “active listening”; empathy; nonverbal communication; opening, controlling and closing an interview. Information gathering skills include taking of the history of patient's complaints and a life history; carrying out a physical examination, taught also in other parts of the curriculum; these also includes skills necessary to assess the functioning of the patient's family and the family's ability to contribute to the patient's care. Information-evaluation skills include selecting the crucial pieces of information for making a diagnostic formulation and undertaking a differential diagnosis, making a personality assessment, evaluating the role of personal and social factors in the patient's behavior, formulating a plan of management which includes the points at which referral to a specialist will be appropriate. Information-giving skills include passing information to patients to promote health, explaining the implications of a diagnosis and informing patients about the beneficial and potential adverse effects of treatment. 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In the countries medical students need to receive additional teaching in Psychiatry during the medical psychiatric disorders form such a part of the work of primary-care doctors. This additional psychiatric training in developing countries should the medical curriculum as a It should also after as part of training and medical education The teachers in the countries concerned will be able to the necessary of this additional for general practice after In to the knowledge the skills needed to psychiatric problems within a system appropriate for primary care will be as also the skills needed for most by general and the knowledge of to to specialist services. Attitudes that will promote mental health and have also to be A substantial part of this additional teaching should take in the community in which students are to work and skills necessary for the to do work in with staff are The international of for primary care is a guide to the additional teaching needed for primary care. and resources It is an important of psychiatric teachers to the medical of the value of Psychiatry in the general medical curriculum. The is made by (a) the of psychiatric problems in the general practice of the substantial factual basis of the and the need to teach skills. this importance has been the time needed to teach the will about the of teaching that are required for the core curriculum depend in part on the of teaching with other and the extent of teaching of skills during other parts of the medical curriculum. The of time in the Psychiatry will also depend on the other opportunities for teaching behavioral and psychosocial aspects of Medicine in the curriculum as a resources need to be for this In to this other periods of teaching are First, opportunities to teach Psychiatry are required during other clinical in and general practice Secondly, an of time for and in the curriculum should be to Psychiatry and mental-health Such teaching should be at in the by the and of the medical school, to the opportunities available and the skills of the these in a period of is required to teach however, some of this teaching can be the of a the should be less than resources need to be to provide teaching and learning during this The of the within the course is generally best in the clinical that some additional time for teaching is in the first and In the are taught in the first of undergraduate During the first there are about of teaching in various psychosocial In the are to teaching of In the there is a of of Psychiatry to each for and and for Medicine and In the teaching of mental disorders in and was in During the it acquired the status of a major clinical to after and Medicine and of and and there are of Psychiatry teaching in a about of the It is a major clinical discipline with a at the of the In Psychiatry its in medical education in the However, it through major changes in the following the Medical recommendations in medical which the importance of and Psychiatry in medical teaching and practice. are to the behavioral course during basic medical During the clinical students first learn skills and a during the and a Psychiatry for This is by a as in other subjects. There is a in on the teaching of Psychiatry the of a new curriculum in the Psychiatric aspects of various clinical disorders are from the first by in Psychiatry and Most of the clinical teaching in the and years of the course and of and Students are the to develop skills in and are required to in detail as as a on the of they are The teaching involves personal In the last three many countries have medical their provide for a substantial time for the teaching of Psychiatry, to inadequate resources and of trained the are not Most are is In the has there is a for of teaching of during the first years of the medical by a in Psychiatry during the and to of staff, this has been to only However, it one of the major taught and in the the others being and and Medicine. The broad of the course are that students should learn the importance of psychological factors in social and clinical context, psychiatric illness and be able to at primary care to serious conditions such as and mental The specific objectives are to students to recognize major psychiatric disorders in the community and be able to treat some of and others to the appropriate (ii) to with psychiatric and (iii) to understand the role of psychological factors in physical disorders. and have the of Psychiatry undergraduate Psychiatry curriculum and made Psychiatry a for THE the time of in many committees and forces have emphasized the importance of in the undergraduate Psychiatry teaching by the of training in Psychiatry, (ii) making Psychiatry an for teaching and and (iii) the Psychiatry curriculum at the undergraduate level. It is not a that even in the 21st century, as many as of medical in India do not have of The of medical students to mental disorders is limited to some to the mental but conditions there in among medical students rather than developing their in mental-health problems. the by the Medical of India as on only to Psychiatry and a of in Psychiatry is taught as an discipline of it has an curriculum This is in of recommendations of various including one by the Medical of India to Psychiatry a with of In the following are required on an the curriculum and the of with the time to Psychiatry there has been a need of social and behavioral in the training of medical to more aware and and develop a in primary-care setting have that as many as of patients health for a mental-health are already the of mental-health problems. However, to their effectiveness in and common mental and behavioral health problems in the community, including screening and for and other they must be training at the undergraduate level with frequent refresher as part of medical education training curriculum should also include application of psychosocial in the of and policy development and teachers of has been the changes in knowledge and Medical have such a changes in the as as of its This may a on the teachers who, in a Indian medical may already be with high clinical and must be in to their teaching skills by application of and other of information in mental-health systems are major in many by the development of has been integrated into the overall health There is an that of community mental-health care that are not on the specialist be more There is now from the effectiveness of such However, most of the to has been in the developed countries is needed in the developing countries to this and guide in mental-health care. It that for this to at and level, we need to the undergraduate teaching of Psychiatry, a to the essential mental-health care. It is clear that the mental-health needs of this country. there has been a for in countries and leading to of trained from India to these there will a between and of within the country. India has to with its mental-health it has to develop of care as in other countries, including developed Many international World Federation of Medical Education and World Psychiatric Association have developed a core curriculum in Psychiatry that can be as a by various countries for developing their own curriculum. Indian Psychiatric must take in this to about necessary changes in psychiatric teaching at the medical of India level. The benefits of the psychiatric component in undergraduate medical education the primary objective of future doctors with better psychiatric considering the that trained doctors are every in India who do in mental-health needs of the country.