Academic Psychiatry has devoted the current issue to papers from various nations across the world. As we become more interconnected and interdependent, it is desirable for psychiatric educators to share innovative educational programming among international institutions. Beyond the value of learning novel approaches, appreciation of the practice of psychiatry in different nations enriches the cultural experience in patient care and education. In recent years, Academic Psychiatry has emphasized its desired role to be truly international and to support academic psychiatrists everywhere (1, 2). Bidirectional flow of educational ideas and initiatives (indeed, “multidirectional” flow may be a more accurate term) through the journal is highly desirable to support psychiatric educational needs in every country (3). Certain areas of clinical care and education (such as cultural psychiatry) may well be better advanced when embedded in an international perspective. As part of its role in promoting “world literature” in psychiatric education, the journal will continue to attract, mentor, and promote international authorship. This issue reflects recent efforts to include the global academic psychiatry community. Active engagement of international colleagues and trainees represents a high-priority growth opportunity for the editorial mission of the journal. The articles in this issue construct a tableau showcasing five aspects of international psychiatry coincident with the mission of the journal: 1) psychiatric education; 2) clinical aspects of cultural adaptation; 3) psychiatric practice in other medical specialties; 4) physician health; and 5) global clinical experience.
Academic psychiatrists often assume leadership roles in psychiatric education, and investigating international approaches to pedagogy can enhance training experiences for educators and trainees alike. Several papers in the current issue address methodological issues in psychiatric education and touch on similar themes that are challenges in many psychiatric educational settings: the evaluation and application of evidence-based teaching methods in various cultures, the objective assessment of perceptions of and attitudes toward psychiatric illness and psychiatry, analysis of academic mentorship, and the establishment of psychiatric curricula in developing nations.
Zahid et al. (4) report on their experience from Kuwait in implementing an Objective Structured Clinical Examination (OSCE) in the undergraduate psychiatry clerkship. This intervention is in keeping with a worldwide trend toward more experiential, competency-based, clinical skills examination procedures (5). The authors followed two consecutive student cohorts, one before and one after the curriculum change, representing a real-world “quasi-experiment.” There was no decrement in overall student test scores after this change. As most students will go on to other specialties, it is notable that the authors prominently included the psychosomatic medicine topics of cognitive impairment and delirium as OSCE station topics.
Shankar et al. (6) used questions derived from the Attitudes to Psychiatry Scale (APS) in a commingled sample of 549 medical students from Ghana and India. They found that themes of inspiration from medical school, the stigma of psychiatry, the scientific basis of psychiatry, and the perceived effectiveness of psychiatric treatment were all important factors in students' perceptions of psychiatry, suggesting that educators may wish to address these areas directly in educational programming. Psychiatric academics may consider adopting a “multipronged” approach to facilitate students' appreciation of psychiatric illness, clinical practice, and residency training to accurately-but-enthusiastically represent the specialty to perhaps skeptical, but still-undecided, medical students.
Tor et al. (7) provide a quantitative study from Singapore on the desirable attributes of a psychiatry mentor. They surveyed psychiatry residents and practicing psychiatrists on 40 qualities felt to be associated with both quality clinical psychiatric practice and valued psychiatric mentoring. Responses clustered according to four overarching themes (professional, personal values, relationship, and academic-executive). A detailed factor analysis showed both convergence (e.g., “professional” was the the highest-rated value in both groups) and divergence (e.g., “relationship” was rated second-highest in mentors, whereas “personal values” was second-rated of the desired values in a good psychiatrist). This study demonstrates that mentorship must “go beyond” just the modeling of clinical skill: “…a good mentor needs to be a good psychiatrist, first and foremost, but requires additional skills beyond that.” This study accentuates the need for training and modeling in mentorship as a specific academic skill (8).
Shefet and Levkovitz (9) describe a teaching initiative of a national, interactive, 2-day workshop in psychiatry, including all Israeli psychiatry training programs. This program involved both residents and psychiatry faculty members in problem-based learning using case material. Such gatherings may be particularly desirable for geographically small jurisdictions where it is practical to assemble participants from several institutions. The benefits of direct exposure to faculty members from other institutions, informal networking, and the sharing of research and educational programming are obvious benefits of such a model.
Laugharne et al. (10) describe the establishment of a rudimentary psychiatric curriculum in Ghana, a nation of 20 million people, with five psychiatrists. After a 3-day review course in psychiatry for medical students, there was a 50% increase in psychiatric factual knowledge and a transient increase in psychiatry as a career choice. It is encouraging to see that even a brief educational experience, in an austere environment, can have a notable effect on knowledge and interest. This project speaks to the interest in the developing world in acquiring practical psychiatric knowledge. Better-resourced systems may consider partnerships with developing world academic institutions to efficiently enhance psychiatric education in these nations with well-chosen, brief, but timely educational interventions.
Psychiatric Aspects of Cultural Adaptation
Challenges with cultural adaptation, a common stressor in our mobile and interdependent world, may manifest as psychiatric illness in many of our patients. Therefore, cultural psychiatry has emerged as an essential part of psychiatric training for understanding the life experiences of our patients, and the challenges of cultural adjustment among physicians providing care.
Pan and Wong (11) present a study of cultural adaptation of Chinese students in Australia and Mainland Chinese students in Hong Kong. This parallel design allows for apt comparisons of the acculturation challenges between these groups. Although the subjects were graduate students, the experiences of medical students with similar cultural adjustment challenges may be quite similar. Both groups experienced negative affect associated with stressors of academic performance and cultural marginalization. The Chinese students in Australia experienced more acculturative stressors and more negative affectivity than the Hong Kong-based Mainland Chinese students. The Australian-based students experienced the affective impact of an assimilation strategy, and cultural differences predicted negative affect in the Hong Kong cohort. Beyond the clinical reminder of having psychiatrists more attuned to such attributions of negative affect in students in a new cultural environment, psychiatric academics would do well to pay attention to cultural pressures and cultural compensatory coping strategies in many of their own students.
Psychiatric Practice in Other Medical Specialties
Increasingly, the major proportion of psychiatric illness management is rendered by physicians in primary-care specialties, with psychiatrists functioning at a “consultant” level in many systems. The obvious efficiencies of such systems, wherein the specialty-care physician focuses his or her sustained attention on more seriously ill patients, are desirable. However, empowerment of primary-care physicians in managing less-severe psychiatric illness then becomes a priority of psychiatric education. Our authors have provided us with papers that address methodological approaches to primary-care psychiatric education.
Shirazi et al. (12), from Iran, examined the “standardized patient (SP)” paradigm in the evaluation of primary-care physicians. SPs were scripted to portray depressive disorders and then used as observers for the in-vivo assessment of primary-care physicians' management of mood disorders. With thorough preparation, the SPs were able to achieve high levels of validity and reliability. Given that many healthcare systems rely on empowered primary-care physicians to treat most depression cases, it is encouraging to see that scripted psychiatric SPs can play a useful role in quality-control for these primary-care encounters.
Takahashi et al. (13), from Japan, addressed the training of nonpsychiatric residents in psychiatric topics. Much psychiatric care in Japan is rendered by “psychiatrically-empowered” primary-care physicians. The authors describe a mandatory 1-month clinical experience in psychiatry in a primary-care training program with a survey for the perceived “sufficiency” and “usefulness” of the psychiatry experience, concluding that “the emphasis should shift from training in schizophrenia to training on useful items for nonpsychiatric residents, especially training on hypnotics, delirium, mood disorders, and dementia.” Psychiatric educators charged with training of other specialty residents are reminded of the place for a needs-assessment and the tailoring of clinical teaching to “fit” the likely patient profile to be encountered in primary care, such as dementia, delirium, mood disorders, anxiety disorders, and substance abuse.
Physician health is an important area for psychiatry, inasmuch as the health concerns for our fellow physicians are often related to psychiatric illness. Therefore, psychiatrists may assume a significant role in promoting and facilitating physician health. Adequate surveillance of physician mental health and availability to treatment services are desirable endeavors for optimal functioning of residents in demanding postgraduate training programs.
Mesa Ríos and Muñoz (14), from Mexico, studied the use of the SCL-90 to assess psychiatric symptoms in a sample of 30% of all the psychiatry residents in Mexico and compared their scores to population norms for gender. Although the residents were less symptomatic than expected in population norms, the female residents had more symptoms than male residents, suggesting that female residents may benefit from some extra surveillance as they progress through the rigors of specialty training.
Zuardi et al. (15), from Brazil, evaluated emotional burden and stress among psychiatry residents as compared with other healthcare professionals (a multidisciplinary comparison group). They found a greater level of job-related emotional burden among the residents. This is of particular concern to psychiatric academics, since there may be something specific to psychiatry residency per se that is emotionally problematic. This article adds to previous calls for more attention and intervention for residents in emotional distress.
Finally, the potential benefits of international experience in psychiatry include the study of illness in unfamiliar environments and opportunities for international collaboration. Our contributing authors serve to make current and timely contributions to the development of our specialty across the world. Five of the papers in this issue address various aspects of international experience as offering benefit to the developing clinical and self-awareness skills of psychiatry residents. The process of learning to function in a novel and unfamiliar environment, the surmounting of the administrative and logistical challenges involved, and the experience of patients in different social environments may offer lasting educational value to psychiatry residents.
Ballas (16) reflects on his experience as a U.S. psychiatry resident who completed a clinical elective in Japan. He describes experiences on this rotation from several aspects: clinical experience, pedagogical, administrative, and cultural. Clearly, he experienced “more than 3 weeks' experience in 3 weeks' time.” This account is recommended reading for training directors who may facilitate residents' pursuit of international placements. As the world psychiatric-academic enterprise becomes more interconnected (clearly, a laudable goal) then facilitating such international training experiences could become institutional priorities.
Malik et al. (17) describe the experience of starting a cultural psychiatry rotation in Bermuda by a U.S. psychiatry residency program. Small, relatively nearby nations may not always be initially considered for such rotations, but the experience of working within a small, relatively isolated psychiatric care system (for example, there are only five full-time psychiatrists and one inpatient unit in Bermuda) poses specific challenges, even in a prosperous nation. Also, geographic isolation may yield clusters of genetically-determined psychiatric illness rarely encountered in larger and more culturally-diverse nations.
Morse et al. (18) describe an innovative approach using modern communications technology (voice-over-Internet technology and e-mail) to accomplish resident clinical supervision in an environment with few local educational resources (Palestine). Optimal electronic infrastructure supporting contemporary communications technologies may not be universally available, so one must adjust expectations accordingly. The authors provide a good example of creative and realistic application of information technology to support the supervision needs of this rotation experience.
Belkin et al. (19) surveyed U.S. psychiatry residency training directors on the state of the art of international rotations. Although the vast majority of respondents attributed a great deal of importance to global mental health education (with particular value in cultural competency consolidation), only a minority of respondents indicated that such opportunities were available for residents at their departments. The difficulties cited in arranging for such rotations included challenges in accreditation, financial constraints, and faculty/administrative support. This disparity between “interest” and “accomplishment” so described suggests that the barriers to more effective use of global placements are not philosophical, but practical. This article shifts the debate from “Should we support international electives?” to “How can we creatively find solutions to make this happen?”
Our creative authors have provided the journal with one of its most geographically (and conceptually) diverse issues. It is heartening to see a worldwide group of creative psychiatric educators “pushing the envelope” to address some of the obvious challenges facing academic psychiatry in this period of international educational evolution. Academic psychiatry, like other specialties in academic medicine, currently has unprecedented opportunities for international collaboration and exchange of important information. Simultaneously, the challenges of training physicians to function in diverse medical-care delivery systems may never have been greater, with the future offering both great promise and worrisome uncertainty (20).
Academic psychiatrists may benefit from regular review of international educational initiatives because other systems might operate with more flexibility and less “routine” and serve as “educational laboratories” for educational initiatives that have yet to be adopted in larger, integrated, and perhaps change-resistant systems. This may be exemplified by initiatives to deliver psychiatric services more explicitly within the “medical” rather than the “mental health” model. Particularly in the areas of primary-care integration of psychiatric services, smaller and more flexible care-delivery systems may be in a position to create systems of care-delivery that offer more intimate placement of psychiatry residents and faculty than other systems organized around a traditional “mental health” model.
Psychiatric illness is universal, and in a sense, existential. However, the particular experience of such symptoms, the social context of psychiatric illness, and the locally-developed systems of clinical care may vary greatly across nations (21). As such, to truly develop psychiatry as a global enterprise, we need an awareness of the experience of psychiatric patients and psychiatrists in other nations. Indeed, the “competency-based” movement, with its attendant pedagogical benefits, may rightly be expanded to an expectation of international psychiatry mastery as a desirable competency for psychiatrists. Issues such as this one, and other international issues to come, may serve a role in promoting international integration of psychiatry as an appropriately global enterprise.