The psychiatry residency training program at Louisiana State University Health Sciences Center in Shreveport (LSUHSC-S) is a small program. The program began in 1993, and currently consists of 16 residents. There is also a small faculty. The university-based faculty includes 11 M.D.s and several research Ph.D.s. Often, the number of M.D. faculty is less. Most psychiatrists in the community have clinical appointments. Clinical faculty, psychiatrists, and psychologists, provide individual and rotation supervision. Medical school faculty provide most of the lectures. Mary Jo Fitz-Gerald, M.D., (Dr. F.), is the Residency Training Director; Anita Kablinger, M.D., (Dr. K.) joined the faculty as Assistant Residency Training Director in 1997.
Dr. F. received a letter about the American Society of Clinical Psychopharmacology (ASCP) Model Psychopharmacology Curriculum in 1996. The letter said that the curriculum included slides and lecture outlines. Even though the price of $500 seemed expensive, a complete set of slides and outlines would save valuable faculty time. Also, comprehensive attention to specific topics would provide faculty with a valuable resource. The department eagerly ordered a copy.
The Model Psychopharmacology Curriculum content is 702 pages. The size is rather unwieldy, and the construction consists of pages that are bound by a plastic spiral. Dr. F.'s first thought was "Where are the slides?" This volume was obviously not what was expected for the amount of money spent. Faculty looked at the book more closely, hoping to discover what cost the department $500.
The initial index in the book included a detailed listing of the sections of the overview and the Child and Adolescent psychopharmacology section. The section that was listed as lectures is a listing of guidelines for lectures. The guidelines specified that residents should have psychopharmacology lectures at three different levels. The suggested initial course is a "crash course" early in the residency. A "basic" course is in PGY-II and/or -III. Later, residents should have an "advanced" course. Tables list recommendations for each level. The authors discuss other learning modalities, such as journal clubs, case conferences, supervision, and the use of computers. Another section recommends psychopharmacology textbooks and newsletters. This section, however, does not include actual lectures.
Finally, the authors of this commentary discovered that the slides and lectures were in "Appendix A." The index in the book does not specify pages for individual lectures or list the lectures in any way. This was inconvenient in going through sections and assigning them to faculty. The faculty received a revised index last year after completing a survey on the curriculum. The revised index does list the various lectures and specifies which course level is appropriate for each year of residency. A glaring oversight is the lack of lectures for the crash course.
The lecture series consists of slide handouts on various topics. A lecturer could choose to place the information into a PowerPoint presentation, but this would certainly demolish any time savings. Obviously, however, slide handouts are not slides. Also, the presence of duplicate slides and spelling errors suggests the need for better editing.
The Training Director (Dr. F.), arranges the rotation schedule so that all PGY-Is are on psychiatry at the same time. There is a crash course—a very basic overview—during the first month of the residency for incoming residents. All PGY-I residents participate in a lecture series on Axis I disorders. These lectures include topics in diagnosis and treatment. The lectures in the psychopharmacology curriculum, however, do not uniformly contain information on diagnosis. Although this is a psychopharmacology curriculum, these commentary authors wonder why diagnosis is not considered important and where that concept fits into the lecture outlines.
The revised index includes suggested lectures for each year of training. This did not correspond to the suggested topics in the overview. For instance, Appendix A lists anxiety disorders in the basic course for PGY-IIs or -IIIs. Yet Table 5 in the Overview lists anxiety disorder treatments with tricyclics, SSRIs, MAOIs, benzodiazepines, and azapirones as a PGY I—level lecture. Why is the topic of anxiety disorders located in the advanced course? Many residents will see patients with anxiety disorders in the emergency room and benefit from lectures on the subject before the PGY-III year! Yet traumatic brain injury and management of aggression in elderly patients is a basic course.
During the PGY-I course, Dr. F. lectures on psychotic disorders. She had lectured for 2 years on her topic before receiving the curriculum. She prepared a handout for her lecture that discussed diagnosis and treatment issues. The lecture emphasized material that she felt was important for the residents.
Once the curriculum arrived, Dr. F. utilized the pertinent slides for these lectures. The lecture material, however, did not include information that she wanted the residents to know. Therefore, to include all the information that the lecturer wanted to convey, she gave the residents her handout and the information in the curriculum.
The sections on psychotic disorders in the curriculum are "Antipsychotics in the '90s" and "Atypical Antipsychotics." Individual references for each lecture are not listed. Dr. F. reviewed the curriculum slides, wondered about the source of the information, and was unable to locate the appropriate references in the suggested textbooks. References to specific textbooks for each lecture would provide background information for the lecturer who would like additional information. After attempting to use the material for 2 years, Dr. F. decided that she much preferred her original lecture and handout and did not refer to the curriculum material at all.
Dr. K.'s teaching responsibilities in the residency program focus on affective disorders and advanced/ novel psychopharmacology for PGY-III residents. She also had a concern about issues surrounding diagnosis. Matching the specific diagnosis to the appropriate treatment(s) is one of the most challenging duties for psychiatrists. Dr. K. found much variability in the slides addressing affective disorders. For instance, the slide outline for the lecture on antidepressants is excellent. The slides review the diagnostic criteria of major depressive disorder, dysthymia, and depression related to medical illnesses very well. The section on bipolar disorders, however, is less well organized and does not include diagnostic criteria for this spectrum of illnesses. Other information lacking in the curriculum for trainees includes more information on tricyclic antidepressants and the use of mood-stabilizers in elderly patients and during pregnancy.
This experience was similar to that of other faculty members. The Child and Adolescent section includes one set of lectures, a case for discussion, and rating scales. The child and adolescent psychiatrist on the faculty, who presented the lectures, said that he used the outline for a starting-point. He divided this lecture into different diagnostic categories and augmented the curriculum with information about newer medicines that are now available. He did utilize some of the information to develop his own handouts for the lectures.
A training director would have difficulty just presenting the information from the curriculum and assigning lecturers the material as presented in the book. There is a lot of variability in the quality and content of the slides; for instance, only some of the slides have accompanying text. There are two lectures on antipsychotics. Only one lecture in the basic course covers antidepressants. The Child and Adolescent Psychopharmacology section is the only section that contains a case study and questions for discussion. The material contained in the lecture handouts is too variable to suffice for most residents.
The major advantage of the curriculum is the listing of skill objectives and suggested requirements for patients and diagnosis for psychopharmacology management. The included rating scales are a valuable resource located in one document. The lecture materials may be of benefit in some circumstances.
The primary recommendation for improvement is to lower the cost. The current cost is $700. The LSUHSC-S print shop charges $0.03 per page. It is difficult to determine why the printed curriculum costs several hundred dollars.
One major problem is organization. All lectures should be included. The lectures and lecture outlines should match the initial suggestions in the overview. Consistency of content in the lectures is also beneficial. Additional cases, as in the Child and Adolescent section, would aid group discussion. Many programs may also like to have additional information included about the rating scales so that all users know what a positive finding is considered to be. There should be individual reference lists for each handout.
The last recommendation is that the lecture slides should also be available on a disk. With a disk, the lecturer can move slides around and add additional information. A disk also allows one to make slides and handouts. The authors plan to include a disk with the next guidebook.
In summary, most curricula provide important information for training directors. The recommendations are usually so extensive that one easily becomes discouraged. Psychopharmacology is one of the backbones of psychiatry. With a major cost-adjustment and other improvements, this psychopharmacology curriculum may become a valued asset.
This work was done in the Department of Psychiatry at Louisiana State University Health Sciences Center in Shreveport, LA.