I hear, and I forget. I see, and I remember. I do, and I understand.
Among the many challenges facing psychiatric training programs today, perhaps none is more important than ensuring that psychiatric residents learn how to choose and prescribe medications in a manner that is scientifically sound and maximally safe and effective. The Psychiatry Residency Review Committee (RRC) mandates that: "Training programs must teach residents to gather and organize data, integrate these data within a comprehensive formulation of the problem to support a well-reasoned differential diagnosis, formulate a treatment plan, and implement treatment and follow up care as required" (1). It further mandates that the didactic curriculum should include presentations on the treatment and prevention of all major psychiatric disorders and should provide sufficient experiences in the major types of therapy, including pharmacologic regimens. The curriculum must include "adequate and systematic instruction in psychopharmacology and other clinical sciences relevant to psychiatry." While the new guidelines specify that programs must train their residents to be competent in at least five different psychotherapy modalities, it does not yet mandate competence in psychopharmacological management. Yet, it goes without saying that any modern training program in psychiatry must teach its residents both the science and the art of pharmacological management.
Traditionally, didactic methods of teaching have dominated psychiatric education. All programs provide lectures and seminars on basic principles and practical applications of psychopharmacology; and all offer some form of "apprenticeship" on inpatient units and outpatient services, where faculty role model by caring for patients and/or supervising care provided by house staff. Yet, these traditional modes of training may not be fully satisfactory. Clinical psychopharmacology training in Canada (2—4) and the United States (5) has been described as inadequate. In addition, high failure rates on both oral and written specialty board examinations (6) suggest room for improvement in psychopharmacological teaching effectiveness.
Traditional teaching methods have been criticized for a number of reasons. The first of these is information overload. There is more information about pharmacotherapy than can possibly be imparted during medical school or residency, and much of that information is likely to change within a few years. Information taught in lectures is often forgotten, and not always applied clinically. It is therefore more important to teach residents to identify their own knowledge gaps and develop self-directed learning habits. Another critique lies in the passive transfer of expert knowledge. The responsibility for teaching in lectures lies with the teacher. Residents have less responsibility for their own learning, and can become less motivated for their own ongoing discovery. Finally, traditional teaching formats emphasize only the teaching of knowledge, and fail to emphasize important skills and attitudes necessary to become good physicians. Clinical judgment, critical thinking abilities, development of interpersonal and reflective skills, professional identity, functioning as a team member, and an attitude of continued learning are all critical skills and attitudes for physicians. While some of these are addressed in clinical work, they should be reinforced in the didactic setting.
Consistent with the above, recent modification in the Psychiatry RRC’s requirements for all training programs is its mandate that assimilating current knowledge is not enough. Newer requirements include training for competency in: A) patient care, B) medical knowledge, C) practice-based learning and improvement, D) interpersonal and communication skills, E) professionalism, and F) systems-based practice (http://www.acgme.org/outcome/). Thus, programs must not only teach state-of-the-art current information, but must also help trainees learn to investigate and evaluate their own knowledge base and patient care, to appraise and assimilate scientific evidence, and to foster attitudes and skills to keep up with the rapidly expanding database as well as attitudes consistent with a commitment to learning "professionalism." Lectures alone will not serve these complex goals. In this context, psychiatry training programs must place increased emphasis on adult, self-directed learning, providing house staff with the skills to seek, analyze and utilize information effectively. Psychiatric educators have a role to play in contributing to psychiatric residents acquiring these skills.
This article will review some of the commonly used methods of instruction that increasingly play a role in psychopharmacology education. These methods share an advantage over traditional lectures and seminars in that they enlist the active participation of residents, and are thus more likely than lectures alone to enhance the development of professionalism and practice-based learning and improvement. While they may not provide more information than well-delivered lectures, they may be better suited to help students integrate the information, enhance their skills as practicing clinicians and prepare them to continue growing and learning in the future. Since both information and skills are important, lectures and traditional apprenticeship models remain important and clearly will continue to play dominant roles psychopharmacology training, but they are no longer enough. The more they can be complemented with experiential, patient-based and clinically relevant methods of training that take advantage of what we know about adult learning, the more competent, now and in their future careers, our trainees will be. The heuristic methods that will be discussed include: journal clubs, problem-based learning, formalized patient-centered training, games and the use of modern technology in training. In each case, at least one example will be provided to illustrate how such an approach could be or is being used to enhance training in clinical psychopharmacology. Since much of the rationale for each of these methods of teaching rests on theories of adult education, the first section will cover theories of adult learning.
Psychiatric house staff are adults, and contemporary learning theory holds that adult learning should be active and self-directed (7). Some key characteristics of adult learners include:
1). Adults have a foundation of life experiences and knowledge. Thus, instructors must connect learning to this preexisting data bank, and draw out participants’ experiences that are relevant to the topic. In addition, adults learn most efficiently through experiential techniques of education such as discussion or problem-solving.
2). Adults are goal-directed. Instructors must provide goals and objectives in the form of actual clinical situations or patient problems and help participants see that learning the material will help them achieve their own goals.
3). Adults are relevancy-oriented. Instructors need to insure that the learner recognizes the value of the material for their own lives or careers; that is, that what they learn will directly translate into better care for their patients. Most residents will be less interested in knowledge for its own sake than in information and skills that will be useful with patients.
4). Adults must be shown respect. Residents bring a wealth of material to the learning situation and must be allowed to freely express themselves. Multiple teaching formats maximize the probability of addressing residents’ unique learning styles and the use of frequent, constructive feed-back facilitates growth.
These adult learning characteristics suggest that residents must be actively engaged in the learning process. Passively listening to a lecture or observing the "master" will not maximize learning for most adults. It is also important to keep in mind that there are many different learning styles (8) and learning preferences (9). For the reflective observer, journal clubs may be great learning modality, whereas the active experimenter may do better with patient simulations. Independent of specific learning styles, most educators agree that passive learning is deficient (10). Evaluating students’ retention of materials under a variety of teaching methods, Brookfield (11) enumerates the following: from traditional lectures 5%, from reading 10%, from lectures supplemented with audiovisual aids 20%, from demonstration 30%, from discussion 50%, from practice by doing 75%, and teaching others 90%.
Perhaps even more important than increasing retention of new material is enhancing the capacity for continued learning beyond residency. Thus, it may be prudent for the instructor to concentrate more on the process and less on the content being taught. This may be especially true for fields as rapidly changing as psychopharmacology, where today’s truths are tomorrow’s myths. Given the proliferation of new material each day, residents’ must be taught to assimilate new material as it comes along rather than concentrating primarily on learning current information that will be outdated before he or she goes into practice. "Strategies such as case studies, role playing, simulations, and self-evaluations are most useful. Instructors adopt a role of facilitator or resource rather than a lecturer or grader (12)."
In summary, principles of adult learning suggest that reading, lectures and observing, though the most widely used methods of teaching psychopharmacology, are not the most efficient. The more actively engaged the resident, the greater the retention. But even more important, by incorporating principles of adult learning into psychopharmacology training, residents can better learn to adapt new knowledge into clinical practice as it becomes updated and available.
Despite the limited evidence on the effectiveness of journal clubs (12—14), most psychiatry residency training programs offer some form of a journal club experience (15). The desirability of journal clubs has been reinforced by the publication of the latest accreditation requirements for training programs that mandate resident participation in journal clubs and instruction in critical assessment of the psychiatric literature, clinical epidemiology and medical statistics (1). Common objectives of journal clubs are to help residents stay up-to-date with the latest developments in medical or psychiatric knowledge, to learn critical appraisal skills and to develop lifelong learning habits.
Instructors at the University of Toronto, Ont., Canada, described a journal club specifically designed to overcome previously described deficits in psychopharmacology training (16). As part of a larger hospital based curriculum, their journal club included lectures, case rounds and research tutorials. Journal clubs were held biweekly for junior residents. The journal club consisted of an interactive critical appraisal of two to three clinically relevant research articles or reviews on clinical psychopharmacology. Presenters were given their choice of articles. The faculty facilitator encouraged resident presenters to discuss the objectives of each study, the appropriateness of the methodology, and the limitations and applicability of the results. Published guidelines for critical appraisal were suggested (17—24). Evaluations of the journal club experience were generally positive, although case rounds received higher ratings on educational value. Excellent preparation on the part of the presenter and audience participation were considered keys to a satisfactory educational experience.
Reviewing the goals, organization, teaching methods, and evaluation of journal clubs of in postgraduate medical education, Alguire provides a useful guide for developing a successful teaching endeavor (12). First, Alguire describes an all too common scenario many training directors are familiar with. He states that many journal clubs begin with an initial flurry of activity, languish in one or 2 years and are renewed again with a new generation of residents. The three most common goals of journal clubs were to teach critical appraisal skills, have an impact on clinical practice and to keep up with current literature. Most meet at least monthly, usually during the working hours, and typically review two to three articles per session. Journal club longevity was associated with regular provision of food, and the presentation of original research articles. However, restricting journal club articles to only original research was associated with poor attendance. Mandatory attendance was an important component of maximizing resident participation (25). Controlled educational trials have not been able to consistently validate the effectiveness of journal clubs on improving critical appraisal skills. A number of authors have suggested checklists or reading guides to facilitate teaching critical appraisal skills, such as the series of guides published by the McMaster University clinical epidemiology faculty (17—24) or a more recently published series in consecutive issues of Journal of the American Medical Association (JAMA) (26—43).
In his review, Alguire describes examples of innovative journal clubs that use principles of adult learning. In one, residents review a paper that has been alluded to recently by faculty or residents caring for patients. During the presentation of the paper, the resident describes how the results of the study are being used in the care of patients. The faculty leader facilitates a discussion of the study by asking open ended questions meant to critically evaluate the study’s conclusions and whether the local application of the study is appropriate. This format has the advantage of relating the learning to the resident’s immediate experience, presents the material in terms of an actual patient problem, and involves active learner participation (44).
One of the shortcomings of the University of California San Diego (UCSD) approach described in a1 is that the journal clubs are not provided in protected time, and articles reviewed in at least one of the journal clubs are idiosyncratic, tied to the temporary whims of the instructors rather than a systematic presentation of a body of knowledge. Journal clubs could be more integrated into a core curriculum and organized so as to present a predetermined curriculum. a2 and t1 and t2 describe one way journal clubs can be used in a more systematic manner. Instructors at the University of Massachusetts, Tony Rothschild and Sheldon Benjamin, started this integrated program in 1996 in response to frustration with the simplistic prescribing practices they observed in some of their senior residents. It is called the Biological Psychiatry Seminar. Parenthetically, after hearing about this seminar, we at UCSD plan to borrow heavily from it in the near future as we redesign our own didactic curriculum.
Thus, the creative program at the University of Massachusetts meets several goals: it teaches contemporary psychopharmacology, methodically covering all areas deemed critical; it involves residents in the teaching/learning process; it fosters patient based learning, problem solving and prepares residents for their own on-going learning after residency; it incorporates principles of adult learning in its design and implementation; and it finds a way to involve large numbers of clinical faculty through providing continuing education accreditation.
Problem-based learning (PBL) is a method of teaching first adopted in undergraduate medical education by McMaster University in the mid-1960s (45). Currently, more than 90 medical schools worldwide have incorporated some form of PBL in their undergraduate curricula. Several studies have shown that PBL is a successful approach compared with more traditional curricula with regard to intrinsic motivation (46), improving problem-solving skills (47), and long-term retention of learned knowledge (48). Although there is little literature on using PBL in residency programs, this method has particular relevance to Psychiatry because of its focus on interpersonal interaction.
Problem-based learning is one alternative to traditional lecture formats that utilizes principles of adult learning. In PBL, a gradually evolving clinical problem provides the stimulus for resident learning of the basic, psychosocial, and clinical sciences. When provided with a clinical scenario, residents as a group identify the current problem, discuss their current knowledge related to the problem, begin to develop hypotheses, and identify what they need to learn in order to understand the problem. When they have reached the limit of their knowledge, they identify learning issues that they will look up and report back to the group the following session. a3 illustrates a PBL case developed at the University of Texas at Houston, TX, Child Psychiatry Program and describes their experience with PBL.
"Observe, record, tabulate, and communicate. Use your five senses. Learn to see, learn to feel, learn to smell and know by practice alone you can become an expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from a book. See, and then reason and compare and control. But see first (49)."
Bedside education, learning to care for patients under appropriate observation and supervision is the cornerstone of medical education. Most psychiatry training programs start trainees in heavily supervised inpatient settings, gradually lessening the amount of direct observation and supervision and incorporating inherently less supervised outpatient and nonpsychiatry hospitalized patients into the learning paradigm. In the apprenticeship model, residents ideally observe more experienced clinicians participating in the care of patients while also having opportunities to receive direct "real-time" feedback from experts. In the context of learning other diagnostic, interpersonal and therapeutic skills, residents gradually assimilate the knowledge and skills of pharmacologic management. Usually, this "method" involves some combination of residents seeing the patient, writing admission/progress/discharge notes, "bedside" attending rounds, individual and group supervision and multidisciplinary team rounds (where patients may again be briefly interviewed). Many programs have found it useful to include clinical pharmacologists and pharmacists on the clinical teaching "team." Although the apprenticeship model is universally utilized, and has been ranked by residents in at least one survey as a highly favored method of learning (50), it is dependent on the availability of skilled and enthusiastic teachers and the appropriate quantity and mix of patients.
Some programs have found it useful to supplement the apprenticeship model with other patient-oriented conferences and seminars. For example, in the University of Massachusetts model described in a2, a monthly case conference rotated with monthly didactics and bimonthly journal clubs, all meant to reinforce learning around the particular topic of the month. a4 and a5 are examples of two other approaches to applying patient-centered conferences to teach psychopharmacology. The first, developed and taught by Richard Balon, is one variant of the kind of case conference many programs utilize either in or outpatient services. The second, described by Alan Louie at the University of California San Francisco (UCSF) is a unique, innovative program that systematically structures the patient-centered environment.
Case conferences can subserve a number of teaching functions such as problem-solving information retrieval and information, and peer coinstruction. They present a mechanism for faculty-resident interaction and an additional way to evaluate resident knowledge and performance beyond the more conventional examination approaches. Several variants of this case conference are possible (51). For example, at UCSD we have what we call Professors Rounds each month. These are embedded in the Grand Rounds sequence so that all residents and fellows, and many faculty, can attend. During those rounds, one of the PGY-III trainees (in former years it was PGY-II trainees, but logistics have forced a recent change), in rotation, presents a challenging case to the Department Chair. The presentation consists of a comprehensive history, visually aided by PowerPoint, a case formulation, differential diagnosis and unresolved questions about diagnostic and/or treatment issues. In addition, the resident coordinates presentation of ancillary materials, almost always including neuropsychological testing and sometimes including projective psychological testing and neuroimaging. The Chair interviews the patient and then leads a lively discussion. This year, we have also begun asking residents to collect the teaching materials along with references, a log of supervisory sessions about the patient and the presentation, answers to the questions that had been posed, new questions, next steps and follow up as the PGY-III portfolio to help document patient-based learning, knowledge, professionalism and other applicable competencies. We also ask residents to present patients at a number of our specialty clinics such as mood disorder clinic, obsessive-compulsive disorder clinic, dual-diagnosis clinic, etc., led by experts in their respective areas.
a5 illustrates a method of "real-time, patient-centered" psychopharmacology training that simultaneously deals with problems of documentation and reimbursement. Issues regarding financial reimbursement are not inconsequential. Residency training directors have had to face progressive reductions in funds and resources for education over the past several years. More recently, the faculty has been under greater pressure to generate income through patient care or research grants, leaving less time for teaching. At UCSF, consultation clinics have allowed faculty to combine teaching with their "second opinion" practices, thus maintaining their fiscal productivity. Since the attending is "in the room" listening to the patient and providing real-time supervision to the resident, the clinic may legitimately charge full attending fees while training the resident; an added incentive for the attending is that the resident also drafts the consultation report, which they both sign.
The UCSF second opinion clinic model offers a unique training experience, which is also fiscally sound. There are several advantages to this approach: it provides the attending with direct observation of the resident’s interviewing skills and the patient’s presentation; it allows the resident to observe the attending’s interviewing skills; it provides the residents with quick feedback about their interview based on the questions they missed and the postinterview case discussion; it provides vicarious learning (modeling) when the resident observes the attending’s interview and sees whether the attending’s questions successfully open up areas of history that the resident did not elicit; it provides high patient satisfaction that the attending, to whom they were referred for the second opinion, is present for the whole interview; and it provides a financially viable format in which the attending may charge for a complex consultation. In addition, the writing of the consultation report sharpens the way a resident formulates a case, requiring clear and concise articulation of diagnostic and treatment issues, and compliments the consultation-liaison experience of communicating with other physicians. Finally, because it is a second-opinion clinic, it provides residents supervised experiences in how seasoned clinicians approach the most difficult and challenging patients they are likely to see in psychiatric practice.
Can learning psychopharmacology be fun? Although any good elementary school teacher knows the value of making learning fun, and all educational resource stores are filled with educational toys and games, most medical school and psychiatric residencies have found the way to keeping fun out of the curriculum. Finding effective teaching strategies to make mastering psychopharmacological competency more interesting to residents can be a daunting challenge. Academic games are an interactive, learner-oriented method of developing and assessing theoretical and competencies. They can help promote the use of groups, reduce anxiety, enhance the learners desire to learn (52). By promoting group cohesiveness, games can help residents contribute to their own learning as well as to that of their colleagues. Academic games differ from most other games in that the goals are to practice and refine knowledge, identify areas for improved learning and provide reviews prior to examinations (53). Although there are not a lot of psychopharmacology games available at the local educational supply store, or even in the psychiatry literature, an interesting board game, developed to help teach psychopharmacology content and assess knowledge of psychotropic medications for nursing students could be readily adapted for psychiatric residents (54). In that game, the goal is to demonstrate competence in each of 5 medication classifications: antipsychotics, antidepressants, anxiolytics, mood stabilizers and drugs of abuse. The game board resembles a race track and players moves around the board by rolling a dice which takes them forward to a space with cards containing questions (dealing with pharmacokinetics, pharmacodynamics, therapeutic effects, adverse events or management implications of one of the medication classes). When players correctly answer the question, they keep the card. The player keeps going until they cannot correctly answer a question and then it becomes someone else’s turn. The game may go on until each player has successfully gathered at least one card from each medication classification.
The games in a6 illustrate the way one of the coauthors and senior residents at UCSD, TM, adapted two games he had played while rotating on the Neurology Service at his medical school (the University of Iowa).
Modern technology provides many new opportunities to teach psychopharmacology with residents who are increasingly comfortable working in the world of computers, searching the World Wide Web on the Internet, using Personal Digital Assistants (PDAs) at the bedside, and learning through distance mediated teaching in telemedicine. These new technologies continue to evolve rapidly and it has become clear to even the most techno-phobic that they are here to stay. The number of applications, databases, and available hardware and software grow exponentially every year. What is cutting edge today will soon be out of date, but several themes in the use of technology have emerged that appear likely to continue.
Teachings of psychopharmacology through the use of multimedia presentations on computers have been available for over 10 years. These programs usually combine video clips of patient interviews or clinical vignettes with decision-tree questions that advance the presentation and provide specific feedback to the learner. Video of expert clinicians commenting on clinical cases is often utilized to summarize the content. These multimedia-teaching programs were originally developed in several medical school departments, but later were created, refined and distributed by the pharmaceutical industry using compact discs (CDs) and now digital versatile discs (DVDs). They have the advantage of promoting self-directed learning (appealing to adult learners), creating dazzling multimedia simulations of actual clinical material that stimulates learning, and of being utilized by residents at their own convenience and as needed. Disadvantages include the high cost of production in developing scripts, filming, and programming, and the rapid advances in technology that render old mediums obsolete.
Web-based versions of computer driven multimedia presentations are likely to supercede the current CD and DVD-based programs. The explosion of information available on the World Wide Web of the Internet has given faculty, residents and patients alike access to more information then can be reasonably sifted through for accuracy and appropriateness. There are dozens of consumer-based sources of information on the Internet including psychopharmacology websites, psychopharmacology listservs, and available expert consultants at websites who answer questions. Their content varies significantly in quality from site to site. New sites emerge monthly and old sites are often no longer available. Those that are affiliated with professional organizations in psychiatry and with academic departments are generally more reliable. The Internet has also provided easy access to library databases such as MEDLINE, evidence-based databases such as the Cochrane library, and to electronic journals that contain vast quantities of information relevant to teaching psychopharmacology. Residents are generally adept at searching through the Internet to access information and more commonly need faculty expertise to help them focus on the relevant question and information needed, and critically evaluate it for scientific reliability and validity. Several web sites, such as the Texas Medication Algorithm Project (TMAP) can be incorporated into psychopharmacology teaching programs. The Texas Medication Algorithm Project provides treatment algorithm for schizophrenia, depression and bipolar disorders. All materials are available in both English and Spanish and are available on the World Wide Web at www.mhmr.state.tx.us/centraloffice/medicaldirector/TMAPtoc.html. Several publications chronicle the effectiveness of TMAP (55—58). The Texas Medication Algorithm Project foreshadows the development of computer based algorithms, treatment guidelines, and "order sets" that are likely to inhabit hospital based electronic medical records and information systems in the future.
Personal digital assistants (PDAs) are one of the most exciting new tools in clinical work in psychiatry that provide valuable and current information on psychopharmacology to clinicians. Several excellent pharmacology databases exist which can be conveniently carried in PDAs, including the PDR and Epocrates. These databases provide information on all currently available medications and include details on adult and pediatric dosing, contraindications and cautions, drug interactions, adverse reactions, cost information, metabolism and excretion, mechanism of action, pregnancy and lactation class, and space for personalized notes for each medication. A convenient medication search program allows easy access to needed information and potential drug-drug interactions. Most databases are regularly updated with FDA warnings and other important information for prescribers, a process which is easily accomplished through synchronizing the PDA with a computer that has access to the web. A free PDA version of the basic database of Epocrates, which contains all of the features noted above, is available at www.epocrates.com (59). More elaborate PDA-based databases can be purchased commercially and in medical bookstores and are rapidly replacing the classic hard copy handbooks that were once carried by residents.
The multiple capabilities of PDAs, combined with their portability, make them ideal for use by residents. Although synchronous or face-to-face transmission of information is usually superior, the ability to beam information electronically between PDAs and transmit information via synchronizing with networked computers can be useful in teaching and learning. PDAs can also store multiple sources of reference information and can be used to print documents. For example, at the University of California Davis, PDA’s given to each resident contain medical information (Epocrates), reference material, lists of formulary medications and even syllabi from psychopharmacology seminars. PDA’s are smaller and lighter than laptop computers and have most of the capabilities enjoyed by laptops just a few years ago. Grasso and Genest (60) described the use of a personal digital assistant in reducing medication error rates. The use of personal digital assistants is revolutionizing the use of computers in the delivery of health care and is rapidly expanding to medical education. As with web-based sources of information, faculty may be most useful in assisting residents with framing the correct questions and evaluating the reliability and validity of the acquired data.
This manuscript reviews five alternatives to traditional lectures for teaching psychopharmacology: journal clubs, problem-based learning, patient-centered training, games and the use of modern technology. Each of these modalities are meant to impart new knowledge, but, at least equally important, to maximize the probability that residents will continue to grow and assimilate new knowledge and skills beyond their formal training period. Utilizing principles of adult learning, these teaching strategies enlist active participation of residents, and provide them with the skills to seek, analyze and utilize new information over the course of their careers. Not meant to supplement or replace traditional lectures, these techniques, and other like them, should help make learning more fun, useful, relevant and self-sustaining.