One of most important tasks of academic psychiatrists and departments of psychiatry is training the psychiatrists of the future to provide the best quality care and conduct the highest caliber research. The mission of educating psychiatrists has critical public health implications, as the welfare and stability of our communities and society depend greatly on the overall well-being of our citizens. Moreover, the public health ramifications of psychiatric education now extend beyond our own borders, as the globalization afforded by technology, commerce, and science has brought nearly all nations into much closer contact. Research findings and educational efforts by psychiatrists can be quickly communicated anywhere in the world, such that psychiatry itself is becoming a global enterprise. Furthermore, many of today’s psychiatrists have completed some of their training in other countries and bring with them to this country a diversity of experiences that can benefit our institutions.
Yet, surprisingly little work has been done to gather and disseminate information about psychiatric training around the world, including understanding how various countries meet the challenges of providing adequate training appropriate to unique regional needs. This article represents one attempt to bridge this knowledge gap. Such information could help programs learn from each other in order to provide the best possible training in the context of the changing roles of psychiatry in the enormously different environments in which psychiatrists practice around the world.
In addition, learning more about the specifics of training in other countries will help psychiatry programs in the United States to evaluate more effectively applicants who have gone to medical school or were trained in other countries. All training programs in the United States receive applications from international medical graduates (IMGs) each year. In 2006, 2,467 of 3,582 (69%) applicants to U.S. psychiatry residencies were IMGs; 340 of 983 (29%) matched positions in psychiatry were filled by IMGs (http://www.nrmp.org). Most of these applicants went to medical schools we know little about, and many have completed psychiatry residency training in programs we know even less about. Thus, training directors often feel unprepared to evaluate their past performance or future potential.
Recently, there have been some attempts to begin gathering and disseminating more information on psychiatry training around the globe. A joint collaboration between WHO and the World Psychiatry Association (WPA), for example, surveyed 143 national medical societies from 171 countries, resulting in the publication of the Atlas: Psychiatric Education and Training Across the World 2005 (www.who.int./mental_health/evidence/Atlas_training_final.pdf). The results of the survey revealed a general deficiency and a marked variability in training around the world. Many developing small- to medium-sized countries have either no training facilities or cater to a very small number of trainees, and the content and quality of training vary considerably. Table 1 summarizes some of the differences in mental health resources in the 10 countries featured in this manuscript and highlights the enormous inequality of resources devoted to mental health in different parts of the world.
To help meet some of the identified needs and to broaden the scope of psychiatry training around the world while maintaining a standard quality with special reference to local needs and cultural issues, the WPA developed a “Core Training Curriculum for Psychiatry” (www.wpanet.org/institutional/programs2.html). The core curriculum has been introduced in many schools around the world but is not familiar to many training programs in the United States.
To begin to help psychiatry residency training directors in the United States learn more about training in other countries, a workshop at the 2006 American Association of Directors of Psychiatric Residency Training (AADPRT) annual meeting brought together a training director from Sweden (K.S.B.) and five other faculty and residents involved in residency training in the United States who had formerly trained in other countries to describe similarities and differences in training (1). Six of the seven presenters agreed to summarize their material for this manuscript (K.S.B., K.G., H.J., A.S., T.S., and T.Y.). To provide a more representative survey of different approaches to psychiatry residency training around the globe, four additional psychiatrists who were unable to attend the workshop also contributed to this manuscript (R.B., I.E., L.D., and S.P.).
This article aims to provide information on key aspects of various psychiatry residency training programs around the world and to better inform educators on how programs are structured, how residents are evaluated, and the kinds of experiences residents receive. Ultimately, this might facilitate the process of training programs learning from each other. We also hope this report ignites further interest and investigation into this overlooked aspect of residency training.
To put the training of programs in Canada, South America, Europe, and Asia into perspective, we begin with a brief discussion of psychiatry residency training in the United States, followed by descriptions of training in each of nine other countries.
General psychiatry residencies require 4 postgraduate training years (3 if another acceptable internship has been completed) after medical school. The first year (internship) must include at least 4 months of primary care and usually 2 months of neurology training. In some circumstances, one of the years (usually the fourth) can also be counted as part of an Accreditation Council Graduate Medical Education (ACGME) approved fellowship. Programs are monitored and credentialed by the ACGME. Residents are monitored and credentialed by the American Board of Psychiatry and Neurology (ABPN). The ACGME is responsible for making sure programs provide training in each of six core competencies (clinical skills, interpersonal and communication skills, medical knowledge, practice-based learning and improvement, professionalism, and systems-based practice) (2) and five psychotherapy competencies (cognitive behavior, combined, dynamic, short-term, and supportive) (3). In the next revision of the ACGME guidelines, the five psychotherapy competencies are likely to be collapsed to three or fewer and incorporated into the core competency of “clinical skills.” Graduating residents are ABPN “Board Eligible” but must take national written (Part 1) and oral (clinical skills, Part 2) examinations to become “Boarded” (http://www.abpn.com). By spring 2007, Part 1 will be given during the latter portion of PGY-4, and there is preliminary discussion about eventually also moving the clinical portion (Part 2) to the residency training programs.
Residents must have 4 months of primary care during their internship year, 2 months of neurology (usually in the internship year), between 9 to 18 months of inpatient psychiatry, 12 consecutive months of outpatient psychiatry, 2 months of consultation-liaison psychiatry, 2 months of child and adolescent psychiatry, 1 month of geriatric psychiatry, 1 month of addiction, and experience in emergency, community, and forensic psychiatry. In addition, they must have experience treating couples, families, and groups, and they must have supervised experiences with the more common psychological test procedures.
Residents must be provided “protected” time in each year of training to cover a wide variety of topics. The curriculum must include adequate and systematic instruction in neurobiology, psychopharmacology, and other sciences relevant to psychiatry; child and adult development; major psychological theories, including learning and psychodynamic theory; and appropriate material from sociocultural and behavioral sciences. The curriculum should address development, psychopathology, and topics relevant to treatment modalities employed with patients with severe psychiatric disorders/conditions. The residency program is required to provide its residents with instruction about American culture and its subcultures, particularly those most relevant to the particular program and its trainees. And each program must provide an opportunity for residents to participate in research or other scholarly activities in which residents must participate.
Residents must be provided a minimum of 2 hours weekly in PGY-2, -3, and -4 for individual supervision.
Programs are required to document patient logs, attendance at seminars, and to provide both written and oral examinations during training. Programs are expected to use multiple measures of programmatic, faculty, and resident assessment focused on meeting core and psychotherapy competencies.
The psychiatry residency, as with all specialty training, is regulated by the Royal College of Physicians and Surgeons of Canada. Certification in psychiatry occurs upon satisfactory completion of residency, including special oral exams with patients conducted by each university separately, and additional national written and oral exams completed in the final year. Psychiatry requires 5 years of postgraduate training, organized around specific medical roles known formally as CanMEDs (e.g., medical expert, scholar, communicator, health advocate, manager, collaborator, and professional), each with its own specific set of competencies (4). Clinical training is very much biopsychosocial, with expectations of competence in delivering a wide range of biological treatments, including electroconvulsive therapy as well as individual, group, and family psychotherapy. In practice, Canadian universities vary widely in the scope and detail provided in elective rotations, with some emphasizing subspecialty training, others emphasizing more “shared care” with primary care medicine, and others having large research training rotations.
The first year emphasizes basic clinical skills, heavily oriented towards internal and family medicine. Psychiatry training is limited to a maximum of 3 months. PGY-2 consists of a whole year of a general hospital-type rotation, both inpatient and outpatient. This rotation, along with rotations of the next 2 years, constitute the core training requirements mandated by the Royal College as follows, each of which must include at least 6 months of training (some rotations may be combined in certain settings, such as consultation-liaison with geriatric): child and adolescent psychiatry, chronic care, consultation-liaison, substance abuse, and geriatric psychiatry. In the final year (PGY-5), residents choose elective rotations tailored to future career needs, which could include additional training in internal medicine, neurology, psychiatric subspecialties, or research. Additionally, up to 1 half-day per week throughout the final 4 years of the residency may be spent doing a wide variety of clinical or research electives.
In PGY-1 and PGY-2, half a day each week is devoted to core curriculum seminars that cover the topics of psychiatry required by the Royal College. Although not mandated, most universities also provide PGY-5 lectures in anticipation of the final exam. In addition, each teaching hospital department of psychiatry has an active teaching program consisting of didactic seminars, grand rounds, journal clubs, and psychotherapy seminars. Additional didactic structure in terms of specialty rotation training is expected.
Psychotherapy supervision must include a minimum of 1 hour per week for at least 2 years, with additional supervision to ensure basic competence in consultation-liaison, addictions, and geriatric psychiatry. Most universities, though, specify far more requirements, such as specific hours in each of several therapy modalities.
Individuals are evaluated by uniform documents that assess competencies in each of the CanMEDs roles, respecting that different roles will be emphasized in different rotations. Observed interviews are a key evaluation process to be utilized by each medical school, as are records of types of patients seen and types of therapies administered.
Major Differences From U.S. Training
The Canadian program is longer by a year, and that allows for further training, usually in the subspecialty area of choice as desired by the resident. Psychotherapy training generally is more extensive, particularly since psychotherapy is remunerated fully under Canada’s health care system (which varies somewhat from province to province, and which even covers psychoanalysis in some provinces!). Finally, residents are fully unionized in Canada, which means that working conditions, on-call frequency, and clinical volumes are all subject to review. This makes for excellent “resident-centered” education, but some feel that entails loss of the faculty’s ability to insist on certain functions.
Psychiatry residency training takes place in 3-year programs in various clinical settings linked to public and private universities. Medical school includes an internship in its 7-year curriculum, which typically occupies the last 1 to 2 years and does not include psychiatry. Chile grants the professional title of “physician-surgeon” to its medical school graduates; the academic degree, however, is not a doctorate but a “licensure” (“licenciatura”). Increasingly, universities are offering master’s degrees and other types of postgraduate studies in specialties such as forensic psychiatry and neuroscience.
Chile began to experience a major change in its higher education system in 1981: higher education was privatized and de-regulated, creating competition between institutions. This change resulted in a proliferation of small private universities, several of which started new schools of medicine and residency training programs, and stimulated a renewed interest in the accreditation of undergraduate and postgraduate medical education, as well as in achieving a consensus among the various stakeholders regarding minimum curricular and training requirements. Further, these efforts have been combined with a growing interest in the transformation taking place in the United States and other developed countries toward outcome-based education and assessment of professional competence.
Psychiatry residency training programs developed a nation-wide admission system that includes group administration of an abbreviated Rorschach test and interviews of candidates by faculty of each participating program.
Residents usually spend 12 consecutive months in inpatient psychiatry, 12 consecutive months in outpatient psychiatry, with the remaining 12 months more or less evenly divided among consultation-liaison, neurology, child and adolescent psychiatry, and primary care clinic.
Most programs lack truly protected time for didactics, with the exception of a year-long weekly didactics course on topics such as psychopathology and psychopharmacology, available to second-year residents from programs located in Santiago, the country’s capital and largest city. Small group seminars, journal clubs, and group and individual supervision are the preferred learning activities. Many programs offer weekly Balint-type groups that last from a few months to a year.
Residents receive between 1 and 2 hours weekly of individual supervision. Some programs have a designated academic mentor, with no evaluative duties.
Residents are evaluated by faculty after each rotation and every 6 months in annual rotations. Some of the most competitive programs have oral examinations in front of three faculty members after each rotation. The equivalent of medical specialties boards in the United States are grouped under the umbrella of a single corporation, the National Autonomous Corporation of Medical Specialties Certification. The corporation administers specialty-specific oral examinations for 47 medical specialties, including adult psychiatry and child and adolescent psychiatry. Specialty certification is voluntary but is increasingly determining hiring practices.
Major Differences From U.S. Training
Most residents moonlight throughout their training; consequently, the average resident’s working hours in the program are shorter. Moreover, most residents are not paid by the program for their clinical work; instead, they pay for their own training. Another difference is speedy access to medical and scientific information. Even the programs associated with the best endowed private universities do not have electronic access to major medical and psychiatric journals. This is reflected in the average resident having less actualized knowledge of psychopharmacology and neuroscience, compared to the equivalent in the United States. One of the Chilean system’s strengths has been and continues to be psychotherapy. Like in the United States, older clinicians were immersed in psychoanalytic theory and practice, and the shining star of this generation is Otto Kernberg, who has taught at Cornell University since 1976. Throughout the 1970s and 1980s, there was a strong emphasis on systems-based family and couples therapy. During the 1990s, training and supervision in cognitive behavior therapy became widely available, and lately some programs have started to offer training in dialectic behavior therapy.
Medical school in Brazil is 6 years long, the last 2 years consisting of the internship. Until 2006, psychiatry residency required only 2 years of postgraduate training. Recently, the minimum of 3 years recommended by the World Psychiatric Organization was approved by the national residency training regulatory agency, in part as a result of a growing debate about how to restructure the psychiatry training (5). Despite the clear influences of American and European psychiatric models, clinical practice is very different from that of the United States, shaped by the reality of often formidable practical constraints, such as poverty and illiteracy, and varying religious and cultural practices that allow for more creativity and improvisation.
In order to receive accreditation, training programs must meet a minimum number of hours in each setting or subspecialty. Although the formal curriculum is similar to that of the United States, the requirements are not as specifically detailed, and programs vary to a much larger degree. In some programs, residents may be short-staffed and have to take a truly hands-on approach, administering injections and applying physical restraints, while at others, residents have the opportunity to be involved in cutting-edge research.
Most programs have year-long seminars on psychopharmacology, psychopathology, case presentations, and grand rounds, in addition to courses accompanying individual rotations. Psychoanalytic theory is still predominant, though other techniques, such as cognitive behavior therapy, have gained some ground. Overall, seminars tend to have a casual format.
There are no specific requirements regarding supervision. Not all residents have individual supervisors, but most meet regularly with the service chief, ward attending, and chief resident. In some programs, residents have only psychotherapy supervision in small groups, taking turns presenting their cases. One-way mirrors or videotaping are rarely used. Patients are regularly discussed with attendings but not necessarily seen by them.
Programs are required to evaluate residents at least every 3 months, but there are no uniform standards of evaluation. Unlike the United States, programs are not expected to use particular assessment and measurement tools, and the same applies to residents evaluating programs. Evaluations can vary from written tests to performance grades based on work ethics, interactions with other staff, participation in activities, and other criteria (http://portal . mec . gov . br / sesu / arquivos / pdf / cnrm / resolcnrm002_2006.pdf). Graduating residents are eligible to take a written national examination (equivalent to the ABPN’s) and receive the title of specialist.
Major Differences From U.S. Training
Perhaps the main challenge for residency training in Brazil is putting into practice in such a dissimilar reality the knowledge and theories learned from mainstream American textbooks and recent scientific articles. Despite marked regional variations, infrastructure is more precarious, funding for research not as accessible, and the salary is extremely low, even after accounting for cost-of-living.
The 5-year undergraduate course work for medical training occurs at just over 30 medical schools that are attached to various universities across the country. The performance and quality of these undergraduate medical courses is regulated by the General Medical Council (GMC) (http://www.gmc-uk.org). Following graduation, a limited license to practice medicine is granted by the GMC for 12 months. During this time, the doctor has to complete an internship year comprising 6 months of medicine and 6 months of surgery before commencing postgraduate specialist training.
Postgraduate psychiatric training is supervised by the Royal College of Psychiatrists (http://www.rcpsych.ac.uk/). The Royal College runs the Membership Examination, which is the United Kingdom’s equivalent of the board examination in psychiatry. Doctors who wish to train in psychiatry have to be accepted to a Royal College-approved basic specialist training in a psychiatric scheme. Completion of the 3 years of basic specialist training and of both Part 1 and Part 2 of the membership examination makes the candidate eligible to become a member of the Royal College of Psychiatrists, put the degree M.R.C.Psych. after his or her name, and proceed to higher specialist training in psychiatry. All training schemes, whether basic or higher, have to be approved by the Royal College before they can operate; they are reaccredited every 5 years to ensure that the quality of the training and the clinical and educational needs of the trainees are met.
The basic specialist training scheme lasts for 3 years with six clinical attachments of 6 months each. Each scheme is run by a Royal College-approved college tutor and a training committee. One of the attachments must be in adult general psychiatry and one in child psychiatry or the psychiatry of learning disabilities (mental handicap). Trainees must also receive training in a number of subspecialties, including: general psychiatry subspecialties (substance misuse, liaison psychiatry, and rehabilitation); geriatric psychiatry; forensic psychiatry; psychiatry of learning disabilities; child and adolescent psychiatry; and psychotherapy. There are also five basic requirements for the acquisition of psychotherapy experience: the development of interview skills; psychotherapeutic formulation of a psychiatric disorder; a minimum of three short-term cases (12 to 16 sessions), each using a different psychotherapeutic model; one long-term individual case (12 to 18 months) using any appropriate model; and some experience of either group psychotherapy or couples, family, and systemic therapy.
In the higher specialist training which lasts 4 additional years, the “Specialist Residency” can either be in general psychiatry, mix general psychiatry with a subspecialty, or train entirely in a subspecialty. An emphasis is put on academic training and research. Other aspects of higher training include taking part in teaching medical students, basic specialist trainees, and allied mental health professionals clinical audit and acquisition of clinical management skills to enable them to lead a multidisciplinary mental health team and interact with hospital managers when they assume an attending/consultant position.
During the basic training scheme the trainees attend 3 years of didactic teaching, participate in journal clubs and presentation of clinical cases, and undertake library and literature research.
Supervision and Evaluation
All trainee clinical attachments are supervised by a psychiatric attending who is approved as an educational supervisor by the Royal College. Each trainee clinical attachment is accompanied by a progress report from the educational supervisor. The progress of acquiring and developing clinical skills is documented in a training log. There is also the Membership Examination, taken in two parts: Part 1 can be taken after completing a minimum of 12 months of psychiatric experience. The format of the examination includes a written multiple choice questionnaire (MCQ) examination and the Part 1 Objective Structured Clinical Examination (OSCE). The OSCE is a standardized exam to test the applicant’s clinical skills. It comprises 12 stations which are chosen with a view to sample across the range of psychiatric knowledge and skill areas. Part 2 can be taken after 30 months of psychiatry training and consists of both written and clinical parts.
Major Differences From U.S. Training
Training in the United Kingdom includes 5 years of medical school, 1 year of a medical/surgical internship, 3 years of basic specialty training and 4 years of additional higher specialty training for preparation as a consultant in the National Health Service (NHS) or as a senior member of an academic department. Part 1 of the equivalent of our Specialty Board Examinations can be taken during training. Both Part 1 and Part 2 of the Specialty Examinations contain both written and clinical/oral components. Because doctors in all specialties within the NHS across the breadth of medicine are paid on the same pay scale, potential future earnings are not a factor in a doctor deciding in which specialty to train.
Swedish universities, six of which have medical schools, follow the German academic tradition and there are no colleges similar to the Anglo-Saxon tradition. Medical studies last for 5.5 years and are followed by 18 to 21 months of internship, including 3 months of psychiatry. After completing the internship and passing board exams, the doctor is licensed to practice medicine anywhere in the European Union.
There is a long tradition that senior medical students take temporary jobs as junior doctors and they are encouraged to try different specialties before completing internship. Thus, most young doctors obtain experience in several specialties.
The residency programs are set individually in accordance with national requirements, and the resident can start at any time of the year (http://www.svls.se/cs-media-old/svlsutbpdf/uploads/000086116/psykiatri.pdf). Any hospital can employ residents. Residents in small departments receive additional training in subspecialties in larger departments. There are no compulsory inspections of the clinics offering residency training.
A residency should last for at least 5 years, usually starting with 1 year of inpatient general psychiatry, followed by 1 year in an outpatient unit. In addition, psychotherapy training usually starts early during residency and lasts for 1.5 to 2 years. The psychotherapy courses, cognitive or psychodynamic, take at least 1 day/week and require considerable study time in order to pass a formal final examination. The residents also have patients in psychotherapy under supervision during this time.
After the first few years, residents rotate outside their home clinic, doing a year in child and adolescent psychiatry, forensic psychiatry, addiction and/or geriatric psychiatry. A year of internal medicine and neurology is compulsory. The final year of residency is completed at the home clinic in a more senior position.
The most important part of training is the daily work under the supervision of senior staff members. One of them is appointed as a mentor and meets with the resident at least once a month during the 5-year period. In addition to the extensive psychotherapy course, the resident attends several courses offered on a national level, and participates in national or international meetings. All departments offer some continuing education. Small clinics, with less to offer, are likely to give generous allowances for courses and congresses.
The resident is continuously evaluated by the mentor and other senior doctors. Psychotherapy training is carefully supervised.
The head of the department, the training director, and the mentor are formally responsible for the residency training. The head of the department decides when (s)he should apply to the National Board of Health and Welfare for a specialist diploma. There is no board examination.
Major Differences From U.S. Training
The Swedish system is characterized by freedom under responsibility. Taking a long time off from the residency, for raising children or doing research, usually poses no problem, since all programs are individually scheduled. A longer period of training gives opportunities for deeper understanding and personal growth. About 15% of Swedish doctors complete a Ph.D., which should take at least 4 years full-time, and publish four original papers in international peer-reviewed journals.
Residency training directors are new to Sweden and their position is not well established. The lack of a specialty board exam has several important implications. For example, it is very hard to fail someone. Money speaks, and the head of department may hesitate to send residents to other departments for rotations and may pass residents prematurely because of the lack of specialists.
The present system has been in use since the late 1980s and will change shortly to focus on more structured training and examination. Sweden has been a member of the European Union for 11 years, and harmonization with the diverse European countries is essential.
Until recently, residency training in the Czech Republic was a “trial by fire.” Residents were basically on their own, admitting, discharging, and deciding about all treatments at full speed. Residents took night calls for the entire hospital right away. Clinical training and education remained primarily an apprenticeship, without much structure or formal curriculum. The training requirements consisted of 3 years of adult psychiatry with mandatory 3-month rotations in internal medicine and surgery. There was no mandatory supervision nor were there lectures at the “training” institution, but 1 day of lectures each month was provided at the Postgraduate Institute for Continuous Education of Physicians. There were no requirements for any training in psychotherapy. The 3-year training was concluded by a Specialty Examination. Subspecialty training (e.g., child psychiatry, geriatric psychiatry, sexology, and addiction psychiatry) usually took another 3 years.
In the last few years, however, training in psychiatry in the Czech Republic has undergone profound changes, as will be described in the following sections. It should be noted that this description is relevant for adult psychiatry training only, as child and adolescent psychiatry, geriatric psychiatry, and others will be specialties on their own with their 5-year training requirements.
The new training requirements call for 60 months of training at an accredited training site. There are mandatory and elective rotations. Mandatory rotations include 30 months of adult inpatient psychiatry (starting with a minimum of 6 months of acute inpatient care, and including at least 3 months of psychiatric rehabilitation and 1 month of crisis intervention), 6 months of outpatient psychiatry, and an additional 15 months of in- or outpatient psychiatry, including 3 months of addiction psychiatry, 3 months of child and adolescent psychiatry, and 3 months of geriatric psychiatry. Required are also 3 months of internal medicine (which includes work at the ICU) and 3 months of neurology. The list of possible electives includes: 2 months of research, 2 months of psychiatric rehabilitation, 2 months of sexology, 2 months of psychosomatic medicine, 2 months of community psychiatry, 2 months of crisis intervention, 1 month of forensic psychiatry, 1 month of spa for psychiatric patients, 1 month of prison psychiatry, 1 month of geriatric psychiatry, and 1 month in a nursing home or a similar institution (the total length of training may exceed 60 months).
The requirements also mandate a formal education, at least 28 days/year, including a weeklong course (in PGY-1 to -4 at the accredited training site, and PGY-5 at the postgraduate institute) concluded by a written test, certified participation in educational and scientific meetings, a minimum of 200 hours of psychotherapy training in an accredited psychotherapy institution, 3 days of basic and advanced life support training, and a 1-day health care legislative issues course.
At the accredited centers, the residents are supervised regularly. The scope/time and frequency requirement of supervision are not defined.
The resident must maintain a list of knowledge required and practical skills acquired during the training. The requirements also include regular evaluations by an accredited supervisor (at least every 6 months) and tests of knowledge. After meeting all requirements, the trainee may apply for the Specialty Examination. The application must include a log of required “procedures” (verified by the accredited training supervisor) and a scholarly paper or published article (trainee must be the first author).
The specialty exam consists of a live patient examination with a discussion of diagnosis and management, and an oral examination including three general psychiatry questions and a scholarly paper defense.
Major Differences From U.S. Training
These training requirements are just being introduced and remain untested. They certainly represent a profound change from the previous emphasis on apprenticeship. Though the new requirements are similar to the U.S. general psychiatry guidelines, they may even go beyond the requirements of current U.S. psychiatry training.
Training can be in either general hospital settings or in mental hospitals. Each follows the same curriculum and has the same requirements for graduation. Medical school lasts 4.5 years followed by 1 year of internship and 3 years of residency. To be eligible for becoming a consultant in an academic institution, 3 years of senior residency is a requirement.
Almost all programs have the inpatient experience limited to the psychiatry wards in their own hospital. Residents rotate to different teams within their hospital at various intervals. Each team comprises one attending, one senior resident, and one or two residents.
Inpatient services are fairly similar to those in the United States, with the exception of the presence of health maintenance organizations (HMOs); thus, inpatient units in India resemble psychiatry units in the United States as they existed about 2 decades ago. Reasons for admission included observation for diagnostic clarification, severe distress in the absence of dangerousness, and need for quicker response (e.g., ECT).The average length of stay was 2 to 4 weeks, and no one stayed longer than 6 to 8 weeks. Residents provide pharmacotherapy, behavior therapy, some cognitive therapy, much supportive work and family interventions. They see a significant number of patients with dissociative/conversion disorders. They were managed in the inpatient setting with behavioral interventions, including using suggestion as a therapeutic agent and intervening at the family level. Psychodynamic formulation is encouraged as a tool for understanding but not for treatment in the inpatient setting. The absence of stimulant use is conspicuous, and violent behavior is not common.
Residents start clinics in the first year under the supervision of attending and senior residents. Attendings treat patients in both general psychiatry clinics and specialty clinics (e.g., child and adolescent, addiction, geriatrics, and dedicated clinics such as obsessive-compulsive disorder and sexual disorders). This extended period of outpatient exposure in general and specialty psychiatry is a key component of the program.
Most of the clinical teaching is done on ward rounds and clinics with senior residents and attendings. There is an emphasis on being proficient in descriptive psychopathology/phenomenology, accurate diagnosis (based on the International Classification of Diseases), and psychopharmacology. In formal didactics, which include a case conference, short seminar, and journal club every week, the presenter is always the resident and the presentation is put together under the supervision of an attending. In addition, there is an essential reading list which is discussed on rounds.
Supervision of clinical work is very tight in the first year, with emphasis on more independent decision-making as one grows in experience, especially in the outpatient clinics.
In the first year, residents are assigned an attending for a mentor with whom they work on their thesis. The mentor is responsible for monitoring the resident’s progress, although the senior resident on the team contributes immensely. Feedback is an ongoing process as residents work for long periods with each senior resident and attending.
Oral examinations are given in the third year. The final exams in the third year are similar to the National Board Examinations in the United States (independent examiners are generally held in hospitals other than where the training takes place). Because these examinations are mandatory, programs work diligently to ensure basic competencies.
Major Differences From U.S. Training
The differences between being a resident in India and being a resident in the United States have largely to do with the sociocultural makeup which leads to unique training approaches and focus. Concepts that pervade clinical training in India are beneficence, nonmalificence, and limiting the duration of suffering. Patients rarely quarrel with the care a doctor recommends, and HMO practices are not an interference. This is in addition to the lack of fear of the legal system, and freedom from HMO practices leads to lesser emphasis on proper record keeping and documentation, which may sometimes compromise patient care. As evident from the above, defensive therapeutics is not at all common.
The residents become quite proficient in phenomenology, diagnostics, and pharmacotherapy because of emphasis on these aspects and longitudinal follow-up during residency. Width of exposure to different types of psychotherapy is limited in India. All residents complete a thesis, providing a head start in understanding research. However, research is not well funded, and very few psychiatrists do research at a consistent level. Basic research is almost nonexistent. Exposure to research is thus limited and only projects that can be done at minimal cost are undertaken. Then again, cost of research in India is a fraction of what it costs in the United States.
Psychiatry residency training in China takes place in a 5-year program; a majority of the residents will receive training either in psychiatry departments at medical schools or in large mental health centers. Residents will have extensive inpatient and outpatient training through their daily work with the attending. Since there is no national council or agency to evaluate and monitor training programs in China, the overall quality of the programs, as well as the standard of completion from training, could have huge variations depending on different regions and programs. After graduation from training, almost all residents will stay and work at the institute at which they received their residency training. No national board examination exists but some regions or training programs will have their own written and oral examinations to evaluate the overall competence of the resident before graduation.
The first 4 years of postgraduate training consist mainly of inpatient training, including 6 months of neurology, 3 to 6 months of “organic” unit rotations, and 1 to 3 months of geriatric unit rotations in most settings. Residents also need to rotate in different gender units since male and female patients are often separated in inpatient service units in most psychiatric institutes in China. PGY-4 and -5 have more outpatient and some subspecialties training depending on residents’ interest.
During PGY-1, all residents attend mandatory evening classes twice a week for at least 6 months. Senior faculty give all lectures that mainly cover different areas of clinical psychiatry, especially in psychopathology, classification, diagnosis, and pharmacological management. Optional courses are available in physiology, pathology, epidemiology, and psychiatry research. Residents have to take the written examination after all classes are completed. After PGY-1, no regular classes are arranged. During PGY-2 to -5, residents are required to attend grand rounds (once or twice a month depending on institutions). They may also attend all CME courses or other teaching lectures free if these activities are organized by their training institutions.
During the 5-year training, residents mainly receive training in psychopathology, psychiatric diagnosis, and psychopharmacological management. From the PGY-1 to -4 inpatient rotation, the residents work daily under direct attending supervision and the unit chief doctor will do clinical rounds once a week to discuss difficult cases for diagnosis and treatment. (This so-called “three levels round: resident, attending, and chief doctor” is required in all training institutes and mental health centers). Some programs will have training in individual, group, and family therapies, but these are not included in the curriculum and training tends to be superficial in these areas. Residents can also find a research mentor if he or she is interested in research, but only a few large institutes are capable of doing research.
The residents have to pass the medical qualification examination after PGY-1. From PGY-1 to -5, all residents must have satisfied the rotation evaluation and passed several examinations to prove their competence and meet the standards for graduation. The examinations include the medical qualification exam after PGY-1; the written exam at the end of PGY-1; the psychiatry written exam at the end of PGY-4 and -5; and a review paper and oral exam at or after PGY-5. Successful completion of residency training requires passing both the written and oral examinations at PGY-5, with scoring based on a regional standard that often has significant variations in term of quality. No national board examination has been imposed in China yet.
Major Differences From U.S. Training
In China, most residents live free in hospital dorms during the training; at most large institutes, PGY-1 and -2 residents are required to live in a dorm. The residents often have closer supervision and learn more clinical skills and experiences directly from their attending and chief doctors. They also build up clinical skills by seeing a lot of inpatients and outpatients. Some inpatient and outpatient rotations do not separate completely so that the same resident can follow up a certain amount of discharged patients at an outpatient clinic. This will allow residents to observe the whole course of symptom changes and recovery. However, compared to the United States, there is generally weak training in psychotherapies or other psychosocial interventions. In addition, there are significant regional variations regarding didactics, class curriculum, quality of training, and standard of completion from training programs.
Korea was the first country in Asia to adopt an American psychiatry residency program, between 1950 and 1953, following the Korean War, and started a specialty board examination in 1959. There were about 2,000 board-certified psychiatrists and about 500 residents in psychiatry training programs in 2005.
The programs are well organized and standardized. However, the program requirements are somewhat rigid, and workload is high for both residents and faculty members to follow all regulatory requirements.
The goal of the first postgraduate year is to obtain basic psychiatric knowledge and competency in inpatient care. They are asked to follow more than 20 discharged patients.
The first-year residents in most programs reside in hospital dorms.
The goal of the second postgraduate year is to continue their first-year curriculum and develop competency in outpatient care. Patient care requirements include more than 20 discharged patients and more than 20 outpatients. The goal of the third postgraduate year is to continue mastering first- and second-year curricula and to obtain knowledge of and competence in each special clinical rotational practice in child psychiatry, geriatric psychiatry, and consultation-liaison psychiatry. Patient care requirements include more than 20 discharged patients and more than 50 outpatients. The goals of the fourth postgraduate year include the supervision of lower year residents and development of clinical competency and knowledge in key specialty areas, such as community psychiatry, cultural psychiatry, and forensics. Patient care requirements include more than 10 discharged patients, more than 50 outpatients, and more than 20 consultations.
PGY-1 curriculum topics are psychiatric diagnosis and differential diagnosis, psychopathology, biological theories, psychopharmacology, fundamental psychology and personality development, psychotherapy, theory and practice, emergency psychiatry and neurology, and basic knowledge and care.
PGY-2 curriculum topics continue all first-year topics, theories, and practices of all psychotherapies, treatment of neurological disorders, and electroencephalographs, computed tomography, magnetic resonance imaging, other neuroimaging, and psychological testing. The PGY-3 curriculum includes continuing first- and second-year topics, theories, and practices of subspecialties and basic theories and practices of consultation and liaison psychiatry. The PGY-4 curriculum includes continuing part of PGY-1 to -3 subjects, psychotherapies, consultations and special areas—community psychiatry, cultural psychiatry, forensics, and others.
Supervision and Evaluation
Regular individual and group clinical supervision is provided by assigned faculty members. At least one formal written evaluation per year is required.
Residents are required to publish at least one original article under faculty supervision in either the third or fourth year of residency. The psychiatry board examination has two parts. The Part I written examination includes 100 multiple choice and 20 subjective questions. Part II includes a slide/video clinical test and a psychotherapy test.
Major Differences From U.S. Training
Though the curriculum is very similar to the ACGME’s psychiatry program requirements in general, there are many specific requirements for the training program accreditation:
Residents are also required to publish at least one original article under faculty supervision during either PGY-3 or -4.
Worldwide, psychiatry residency training programs differ in duration of training, oversight by national accreditation councils, required experiences, emphasis on clinical “competencies,” didactic structure, level of supervision, and rigor of evaluation. At one extreme of duration of training, Sweden requires 5.5 years of medical school, usually followed by several years of temporary positions as a junior doctor before or after at least 18 months of internship, followed by 5 or more years of residency training. Thus, psychiatry trainees in Sweden tend to be older than trainees in other countries and seem to be given more autonomy than in most other countries. While training in the United Kingdom is considerably briefer than in Sweden, the additional 4 years of training for those preparing for an academic career, or for work as a consultant in the NHS, add considerable length of training for some. Training in India maintains many aspects of the British model, such as the additional senior resident training required to be eligible for academic appointment. In both Sweden and the United Kingdom, there is more of an emphasis on flexibility for individuals who do not want to pursue full-time training than in many of the U.S. programs. Brazil is at the lower end of the duration of training spectrum, but will be adding a third year of training in 2007. Otherwise, none of the programs requires fewer than 3 years of training.
Most countries provide ample and varied clinical experiences, both required and elective. Notably, some countries emphasize inpatient psychiatry over longer periods and for a more substantial percentage of overall training time than in the United States. This may be especially true in China where the first 4 of 5 years are spent predominantly in inpatient services. The Czech Republic also requires at least 30 months on inpatient psychiatry. All programs provide training in psychotherapy, but the psychoanalytic model is emphasized more in some countries, such as Chile and Brazil, than in others, such as China and India. Some countries require a minimum number of patients treated using various therapeutic modalities, most notably Korea and the United Kingdom. Both India and China emphasize continuity of care by having residents follow many of their patients posthospitalization.
Though some programs emphasize an apprenticeship model of training over formal didactics, especially Sweden and the Czech Republic (until recently), most provide formal didactics throughout. India may be unique in that seminars are routinely taught by trainees, with faculty acting in a more supervisory role. Most programs use a combination of oral and written examinations to help assess residents’ progress. In China, India, Korea, and the Czech Republic, residents are required to pass examinations to graduate from their programs.
Most programs have national governing boards, national standards, and national examinations, although this is not yet the case in China. Sweden has no national board examinations. In some countries, national training organizations seem to have even more standardization and regulatory control than in the United States, most notably in Canada, the United Kingdom, Korea, and recently, the Czech Republic. A few countries (e.g., Czech Republic, India, Korea and China) require some kind of scholarly project or research prior to graduation; many others, however, lack sufficient resources to provide opportunities for independent scholarly activities.
Several programs appear to be changing, becoming more explicit in their requirements and approaching U.S. training in their clinical experiences, didactic structure, and complex documentation (e.g., Czech Republic and Sweden). Increasingly, programs are substituting the language of “competencies” for the traditional model of transmitting knowledge, skills, and attitudes. This includes not only the United States, but also Canada and the United Kingdom, among others. To that end, several countries (e.g., the United States, the United Kingdom, Canada, Korea, and the Czech Republic) require patient or procedure logs documenting clinical activities. The CanMED 2000 project in Canada has many similarities to the core competency requirements recently introduced into U.S. training.
This is the first document of which we are aware that attempts to tabulate and compare key features of psychiatry residency training around the world. This review has several limitations. First, we selected countries and programs using a convenience sample. The descriptions may therefore not generalize to all other training programs from the same countries, or continents not included in this survey. No programs from Africa or the Middle East are described in this report, an omission worthy of an expansion of this work. However, space limitations prevent us from including more countries and training programs. In addition, references are limited, as little previous work has described international psychiatry training. The experiences and perceptions are those of the individual authors, and thus may be idiosyncratic, although attempts were made to provide broad, “factual” descriptions of clinical experiences, didactic structure, supervision, and evaluation of the various programs.
Despite these caveats, we believe this description of different programs around the world provides a valuable first step. We hope our initial foray leads to more discussions of this topic, a more comprehensive survey of a wider selection of programs, and perhaps more face-to-face communication among education leaders from diverse parts of our global village.