In a recent issue of Psychiatric Services, Herbert Pardes chronicles psychiatry’s "remarkable" journey over the past 40 years (1) Pardes writes that in the early 1960s,
in practice, there was little in the way of medication, much use of electroconvulsive therapy (ECT), excitement about psychoanalyses and psychotherapy, and a disparity between a relatively feudal situation regarding therapeutics of serious psychiatric illness and the great investment of psychiatrists in working with neurotic people and increasingly with people with personality disorders. Certainly in 1960, in training centers around the country, the highest calling was to go in to psychoanalytic training. (1)
At that time, psychiatric care was focused on inpatient care, with 650,000 hospital beds in the U.S. There was little outpatient work and almost no partial hospitalization facilities (1). Pardes points out that psychiatry was a field with "diminished prestige and at times poorly justified enthusiasm about the potential of the latest therapeutic approach."
During this time, effective medications for the treatment of psychiatric illnesses (e.g., the introduction of chlorpromazine for the psychoses and imipramine for depressive disorders) were first becoming available. However, the introduction of these therapies was barely noticed by trainees or training directors since, as Pardes noted, the hope of every resident was to become a successful psychotherapist or psychoanalyst, and most training was oriented around this objective. As such, psychopharmacology was taught using an apprenticeship model, with trainees expected to learn about medications by shadowing their mentors, reading in libraries, and applying their knowledge with cases they saw, hoping that something would "rub off" (1).
One of the major developments in all of medicine over the next four decades was the emergence of psychopharmacology that gradually dominated the field of psychiatry. The predominant model shifted from psychoanalysis to biological psychiatry. Over the past decade, neuroscience, as the "new guy on the block," also began competing for increased curricular time. Lectures, and in some cases, journal clubs, dealing with advances in psychopharmacology became mainstays of psychiatric education
During the latter half of the twentieth century, training directors, who were often gifted psychotherapists, increasingly faced the daunting task of integrating the rapidly developing new psychopharmacology and neuroscience into an increasingly crowded curriculum. Some of these training directors did the best they could in often underfunded programs with limited resources. A minority has resisted increasing teaching time for psychopharmacology at the expense of psychotherapy.
Not only has the curriculum become more crowded, but for grant-funded, tenure-track faculty, attention has been increasingly diverted away from teaching. As grant funding becomes more competitive, academicians must spend proportionately more time writing grant renewals, with less time left for teaching. Only the extraordinarily well-funded, the less than 1% "superstars," are able to completely pay for their salaries out of their research funds. And some spend more time in their laboratories and airports than they do in the classroom. Much of the teaching they do is to postdoctoral fellows rather than residents or medical students. In the same vein, less time is allocated for clinician-teachers to teach because most (if not all) have to fund their own salaries, meaning seeing patients to generate revenues. Thus, training programs need help to accommodate the dual issues of 1) more materials to disseminate and 2) less time for faculty to teach.
In this context, this article is focused on two objectives. The short-term objective is efficiently improving the teaching/learning process in psychopharmacology. The long-term objective is more important; that is, improving the clinical practice of psychopharmacology from its current less-than-optimal state. This article focuses on the role of curricula and, in part, on the only relatively complete (meaning it contains both pedagogy and content) curriculum that exists: the American Society of Clinical Psychopharmacology (ASCP) Curriculum. It does not, however, cover the theoretical basis of construction or content (i.e., lecture topics or treatment recommendations) of the curriculum, as this has been well-covered elsewhere (2—6).
For the last two decades, as the knowledge-base has expanded, the development of a model curriculum in psychopharmacology has been encouraged from three principal sources: 1) the American Association of Directors of Psychiatric Residency Training (AADPRT); 2) department of psychiatry Chairs; and 3) a large number of training programs, which either did not have an adequate number of teachers of psychopharmacology and/or did not have adequate resources to mount a comprehensive program. Construction of the curriculum had to take into account the needs of three very different kinds of training programs: large, mid-level, and small. The large programs have adequate teaching resources and many outstanding psychopharmacologists, some of whom are good teachers. The mid-level programs may have one or two "superstars" in a particular field and have some, but not a great deal of resources for teaching. The small programs have few psychopharmacologists on the faculty, usually minimal resources, and have found it difficult to cover the large field of psychopharmacology. Most recently, as neuroscience has become an important part of the field, neuroscientists have gravitated to the large departments, leaving the mid-size and the small programs further drained of teachers for these important areas. And, of course, some of the neuroscientists are good teachers while some are not.
To answer the dilemma of expanding needs in the face of diminishing supply, a psychopharmacology curriculum was prepared in the early 1980s under the auspices of the American College of Neuropsychopharmacology (ACNP). (2) This curriculum was distributed in the 1980s at no cost to ACNP members and to departmental Chairs (nationally). Unfortunately, the curriculum never got the use that its developers naively expected it to receive. It was, however, reasonably well received by those programs that actually used it, and it was translated into several languages for use abroad (2). At that time, little did we know that the process of implementation and integration of a curriculum into a teaching program turns out to be, as one should have guessed, very complex [see Academic Psychiatry, Summer 2001 (25:2)] (3). Use, or lack thereof, seems to be related more to issues very separate from excellence of curricula or content. Critical questions include: Does the program have the necessary teachers to teach it? Does the training director think their program needs help at all? Are instructors willing to use someone else’s material?
In the mid-1990s, this curriculum was completely redone and updated by a committee of members of The American Society of Clinical Psychopharmacology (ASCP) (4). It was specifically designed for psychiatric residency programs with the needs of training directors and teachers in mind. The new curriculum described formats (e.g., lectures, supervision), timing, topics, teaching points, etc. in four areas: 1) objectives, 2) how to teach, 3) what to teach, and finally 4) how to evaluate. It provided teaching materials: topic-by-topic hard copy slide sets, recommendations for organizing the courses, evaluation measures, and references. In addition, the ASCP provided consultation from its experts to help programs accomplish these goals. This new curriculum, including hard copy of slides, was published in 1997 and was sold for $500 to approximately 50 of the one hundred-plus major residency programs in the U.S. (4). The $500 was meant to cover costs related to obtaining materials, printing, marketing, distribution, and marketing funds available for producing the next edition. None of the consultants or writers of the new curriculum or psychopharmacologists who contributed slide-sets were paid for these efforts. Of note, the curriculum was designed and distributed without the involvement of the pharmaceutical industry
A follow up evaluation (5) of about one-half of the programs who purchased the revised curriculum revealed that an estimated one-half of the programs were very satisfied and used much or most of the curriculum. Approximately one-fifth was resource-rich programs, which used parts of the curriculum and were satisfied with the program to varying degrees. One-fourth of the recipients called (all of whom had paid for it) stated that they had not yet had time to look at the program, did not recall having received it, or reported that it had gotten lost somewhere else in their department. A few training directors felt it was not useful or stated they could not integrate it into their resource-poor (as in teachers) program (5). (This evaluation will be discussed in more detail in the following section.)
As a result of this evaluation, a number of suggestions from recipients were incorporated into a second edition to make it more user-friendly. In addition to appearing in hard copy, the lectures were updated, and the slides were put into PowerPoint and offered on a CD-ROM. In June of 2001, the new version was published, both for previous purchasers and for new programs (6).
The main lesson learned from the 1980s ACNP version and the 1990s ASCP version (editions I and II) was that simply distributing the curriculum was like the proverbial "tree in the forest that falls and nobody hears it." It became clear that marketing was mandatory. A later realization was that, without exception, every model curriculum that was developed in psychiatry (not just psychopharmacology) was barely used, if at all, which was a fundamental problem. As Paul Mohl noted, "there has been a palpable sense over the years, of a great deal of energy expended on the way one would expect the model curriculum to be effective, with little tangible effect" (7). That is, in many institutions, there is not a lot of incentive to adopt a curriculum that is suggested by an outside source, as those who are putting forth the curriculum are of the same level of expertise as the faculty at the institutions that are being asked to adopt it. These faculty members may or may not often rely on themselves or on their departments to establish curriculum, and these are not adequate. The issues, then, were to better understand the needs of various training programs and how to do a better job of meeting those needs is a way that will be maximally beneficial and employed. These issues will be discussed in the next section.
As mentioned earlier, the initial version of the curriculum was developed in the mid-1980s by a committee of the ACNP, consisting of teachers of psychopharmacology at four different medical schools (2). This early curriculum was distributed gratis to all of the members of the ACNP and to the Chairs of all of the psychiatry departments in the U.S. It was translated into Spanish, Japanese, and several other languages. A follow up evaluation (8) revealed that it had never been opened in many institutions in the U.S. When the curricula had been forwarded to training directors or when the ACNP member was an integral part of a given training program, they were more likely to be used and were judged both in the survey and by informal networking, almost without exception, to have improved teaching. Unfortunately, this first curriculum never received much use. This may have been because there was no perceived need by experts in outstanding teaching programs and/or because the curriculum was improperly marketed (6).
In 1998, eight members of the committee conducted a follow up telephone evaluation survey of 21 of the 41 psychiatry residency training programs, which by that time had purchased the curriculum for the 1997—98 academic year (5). An open-ended questionnaire was designed to determine 1) whether the curriculum was actually received; 2) whether the curriculum was used, how it was used, and which parts were used; 3) whether the curriculum was used exclusively for training; 4) if the curriculum was not used and why; and 5) ways to improve the curriculum. Finally, we asked respondents to rate (6) "if" and (7) "how much" the model curriculum had improved teaching, compared to the prior year before receiving the curriculum. The interview contacts were the departmental Chair and/or training director. Each committee member interviewed two or three programs. To improve response rate, an attempt was made to match the committee member with the program (i.e., if they knew the training director or Chair). This of course may have introduced positive bias, but it also encouraged "frankness." Programs surveyed included those with very sophisticated and complete programs to those just getting started. By persistently calling the programs, a 100% response rate was achieved.
Nine of 21 (43%) of the programs surveyed were "very satisfied" and used much or most of the curriculum. Four of 21 (19%) programs were "satisfied." This was a group that believed that they already had a good program, and therefore the curriculum was used less (i.e., to varying degrees). Five of 21 (24%) of the programs reported that they had not yet had time to look at the curriculum or they hadn’t received it, or it had gotten lost somewhere in the department. Three of 21 (14%) of the surveyed programs reported that they did not use the curriculum much and felt that it was not useful. The primary problem for the later group seemed to be that there was not enough detail explaining how to proceed. That is, these respondents felt overwhelmed by the sheer size of the curriculum or believed that the curriculum was not user friendly enough for them to begin to incorporate it into their courses. Of the 16 programs that confirmed receiving the curriculum, using the curriculum, and responded to the question, "Did [the curriculum] improve teaching over the prior year,"? 12 programs reported an increase of 1—3 points (on a 10-point scale). Three programs reported no change. (One program rated itself as a 10 on the 10-point scale before and after using it, but said they were "pleased with it.") Mean improvement was 6.4 on a 10-point scale. Other suggestions for improvement deriving from the survey included: 1) updates (at least biannually); 2) computerized slides; 3) a web site; 4) problem-based learning modules; 5) new lecture topics; 6) a list of key points; 7) reading and references for each lecture; and 8) making the lecture outlines more clinically rather than neurobiologically based. The survey revealed that the lecture hard-copy was being used in four ways: 1) the teachers adopted it "en masse" as written, 2) or integrated it with their own materials, 3) or used as a handout, or 4) gave it to the residents and co-taught it with one resident (5).
Overall, these two follow up surveys revealed that where there was a need recognized, and the program used it, the curriculum was found to be beneficial. Where the programs did not recognize a need for the curriculum, it generally was not very useful. The major issue seemed to be the notion, "if I did not create it, I’m not going to use it;" and "we definitely should not pay for it." The ASCP Committee was struck by the paradox of the programs that did pay for it, but never used it.
Returning to the generic issue of model curricula, Academic Psychiatry devoted an entire issue to this topic in 2001 (3). Then Editor, Paul C. Mohl, used a paper that we wrote about the curriculum as the focal point (5). The ASCP Curriculum is described as "what may be the most comprehensive curriculum development process in academic psychiatry" (9). Mohl thoughtfully describes the struggles not just in developing curricula, but getting the curricula to actually be used in programs. He states:
The original Psychopharmacology Model Curriculum, developed by the [ACNP], is often cited as an example of what a model curriculum can be, even though it, too, is more honored in the breach, "by being ignored" than by being used. As it turns out, a very low percentage of curricula developed, are actually used by training directors and/or teachers. (7)
That issue of Academic Psychiatry on model curricula was unusual in presenting the debate and in providing five commentaries by training directors (and other concerned parties) as well as two reviews of our curriculum. The theme of these commentaries is summarized by Professor Jon Borus, Chair of Psychiatry at Brigham and Women’s Hospital in Boston, who pointed out that the teachers should have realized that "they (i.e., model curricula) are helpful, but never sufficient to do the job of teaching, especially in a complex and rapidly changing field like psychopharmacology"(10). We could not agree more.
For a model curriculum issue to be useful and used, several complex issues must be resolved. First, many teachers are reluctant to use someone else’s teaching materials. They feel they cannot adequately do them justice. One of us (IDG) had actually (at the 2001 Association of Academic Psychiatry annual meeting) done a workshop where we asked junior faculty teachers, who had never seen a particular set of curricular lectures, to lecture to a group of peers. All were able to do this without much trouble. Some of them also reported that they had done this many times in their own departments. Other training directors, however, have reported that many faculty members are reluctant to use someone else’s lectures, believing that they are not expert enough to teach residents.
A second issue (as Dr. Steven Dubovsky noted in his review of the curriculum) (11), revolves around how much material must be presented in the curriculum. Is it enough to provide an outline and slides, or are other teaching supplies, such as evaluation, references, and bibliography necessary? Most psychopharmacology lectures assemble a speech by preparing hard copy of slides and lecturing from these slides. It might be beneficial to include lecture notes, key references, and perhaps a brief manuscript on each topic, but a model curriculum is not the same as a textbook of psychiatry. In the same vein, one dissatisfied purchaser of the model curriculum did not realize that there was a slide set provided in the first edition of the ASCP curriculum and therefore did not ask for it (12). In the second and third edition (now published, 2004) (13), the lectures are provided in PowerPoint.
A third issue relates to time, efficiency, and relevancy. Professor Donald F. Klein (an experienced teacher) believes that:
the curriculum is rejected because it increases the workload. The stars think they can wing it. Most important is whether the nonexperts can usefully incorporate this into teaching. I think the complaints were that it was not self-fulfilling, but required more work from the teachers, who have conflicting priorities. Likewise, another disconnect is between what it takes to do a good workup, differential diagnosis and monitoring in terms of time. Given the constraints of managed care, this curriculum often is training doctors for care they cannot actually deliver. That is a disincentive. (personal communication, August 2003).
The fourth obstacle is money, a very strong and emotional issue that polarizes many educators. Program directors have limited budgets and must make difficult decisions about how their meager (compared to some basic or clinical research centers) resources are best allocated. At the same time, it is almost a unanimous opinion among people who market any product that "when you give something away, it gets thrown away." This viewpoint seemed to be validated at the expense of the first edition. So, the strategy with the model curricula has been to ask the training programs to buy it for a nominal sum. Of course, one man’s nominal fee is another’s fortune. The rationale behind this is not just marketing, but that funds are needed to develop and revise the curriculum. The correct balance between having a reasonable cost to improve the product versus that which is affordable to all programs must be adopted. Some program directors have recommended that the ASCP solicit industry sponsorship for further development, marketing, and dissemination.
This leads to another debate: the role of industry. In this issue of Academic Psychiatry, two articles (14, 15) speak to the role of the pharmaceutical industry in teaching pharmacology. It has been the policy of the ASCP Curriculum Committee that the substance (i.e., the content) of the curriculum should be developed entirely without industry input. Support has been accepted for the process of marketing and distributing the curriculum as well as to prepare PowerPoint slides. In the future, Web versions will also need development and may benefit from industry sponsorship.
To help solve these thorny issues, representatives of the ASCP recently met with officers of the AADPRT. One hope has been that the organizations will join together to help improve the curriculum and get at the programs that could use it. Another hope is that the marriage of these large influential associations would make it much more likely that training programs would embrace the project. The objective is that if the curriculum was done well and adequately funded, it is conceivable that every program will use it, thus influencing (almost) every new psychiatrist over years to come, and, by extension, improve the practice of psychopharmacology. A secondary goal is to enhance the evolution of the curriculum to medical schools and primary care where the practice of psychopharmacology has been most problematic. One of the immediate actions of this meeting was to change the term, model curriculum, which carried too many negative implications. Instead, one suggestion is to call it a portable curriculum (i.e., a curriculum that can be carried program-to-program). The hope here is that the organizations can agree on the goals, provide input on contents and implementation, contribute funds to redevelopment, and work together to make this curriculum much more useful than any of the three worked alone.
An issue that will have to be hammered out is whether (as some educators have suggested) use of the curriculum should be linked to psychiatric competency. Should it be required that certain topic areas and teaching points be covered. And, should all departments of psychiatry (approximately 126 at the time that this article was written) and residency programs have it and use it. Is it important to ensure that every resident (given the life and death stakes of clinical practice) be competent? This bears on the issue of how do we determine competency and delineate competencies in psychopharmacology, an issue currently under discussion by AADPRT.
A final spin off is that the curriculum is now in the process of being introduced world-wide—specifically, Japan, Indonesia, and Europe. There is hope that it may even be brought India, a continent that still primarily uses an apprentice model of teaching psychopharmacology (Chittaranjan Andrade, M.D., personal communication, 2003). For such countries, the issue is not just introducing a curriculum, but rather developing an acceptable model that can be adapted for the teaching of psychopharmacology.
In this article, we have discussed the changes in the field, provided a selective review of the teaching - learning process in psychopharmacology in training programs, some problems/obstacles to effective teaching—and focused on the role of "curricula" in the process. Other articles in this issue discuss in detail further solutions to the problems and qualities of good teachers that have been identified.
At this point, we believe it necessary to accept the proposition that scientifically based psychopharmacology is and will be a major player in the panoply of psychiatric treatments. As such, regardless of the obstacles, most educators (and we) would agree that it must be effectively taught and students (i.e., psychiatric residents) must be evaluated in clinical settings before they graduate to determine whether they have learned it.
If one accepts this proposition, then developing a portable curriculum appears well worth perfecting. A central concern—which can only briefly be discussed here, but is described in detail in our curriculum—is how and when to use it. We advocate beginning early in the residency and structuring the program so that a multimodal, individualized approach is used throughout each year of the residency.
If some of this rings true, it is our view that the residency training directors cannot let the issue lie dormant because of a lack of resources. Thus, it is the responsibility of the relevant organizations [i.e., the AADPRT (representing the residents), Association for Academic Psychiatry (AAP), and American Psychiatric Association (APA) (representing psychiatric education), the ASCP, the National Institute of Mental Health (NIMH), ACNP, and AMCP (representing the field of clinical psychopharmacology)] to make it happen. Meaning, programs must be educated to see the need, to be educated to know how and when to ask for help, and, most importantly, to use the help that this curriculum offers. This is not to say that there are not other ways to learn psychopharmacology or other modalities to teach in a program. This may be, however imperfect, the best method now available, especially since it may be the only such curriculum in the world.
We reject notions suggesting: 1) that having this type of curriculum as the focal point of a program divides the field (11) or minimizes the contribution of nonmedication treatments; or 2) that large programs do not need it (their trainees tell us they do); or 3) that small programs cannot afford it (we believe that they cannot afford not to have it); or 4) that since they did not create it, it cannot be effectively used; or 5) that if it does not contain every cutting-edge neuroscience or clinical psychopharmacology finding, it is not useful at all (this is throwing the baby out with the bathwater); or 6) that if the model curriculum is not used, it may not be used because of its limitations. (The problem is that traditionally all model curricula, regardless of the area of focus, have never been voluntarily adapted.) In fact, this curriculum is the most widely used curricula in the history of psychiatric education (7).
In answer to our critics, who, like us, are teachers or training directors (11, 12), we are not saying this curriculum is the total answer, but it is a crucial piece of the puzzle. Likewise, we are not saying that the current version cannot be improved or made more user-friendly; it can. For example, the ACNP developed a geriatric psychopharmacology curricula in 2003, and, with each edition, we have both updated and added new features (The third ASCP edition (13) contains all the features of previous editions as well as features such as pre- and postquestions for lectures and evidence-based algorithms.) Furthermore, we believe that such curricula should be consistent with psychopharmacology competencies in order to give them grit. We, like Jonathan Borus (10), see such curricula as a "necessary, but not sufficient piece" in improving the clinical practice of psychopharmacology in diverse settings, which is of course the underlying objective of the entire project. Lastly, we believe that this effort could be extended to other target groups such as 1) medical students; 2) psychiatrists in practice; 3) primary care providers; 4) government professionals in the field (e.g., NIMH); and 5) other nonmedical health care providers who have a need to know (e.g., nurses, social workers, psychologists, and even the public/media). This effort should not only take place in the U.S., but everywhere there are psychiatric patients and families in need.
Our aim is to drastically change the model for psychopharmacology teaching around the world from an apprentice model to a model based on structured and comprehensive evidence-based curriculum, for which competency can and should be evaluated. Our hope is that, ultimately, clinical psychopharmacology practice can be improved.