In a recent incisive editorial in Academic Psychiatry (1), Herb Pardes, who has long been a leader in psychiatric education, focuses on the “need to train first-rate psychiatrists who are well informed about psychiatry,” with the parallel issues of finding time to teach and having an adequate number of teaching faculty. In fact, surveys suggest that psychiatry residents are not being adequately trained in pharmacology (2–5). In addition, high failure rates on board examinations suggest room for improvement (6). In a recent assessment of psychopharmacology on the American Board of Psychiatry and Neurology examinations, it was noted that “a majority of those who failed the patient section of the oral examination had inadequate performance in the area of drug treatment, indicating that trainees may need additional experience with applying psychopharmacological knowledge in the context of patient cases” (7).
Unfortunately, as Louie et al. (8) and Klein (9) point out, there is a “general lack of empirical studies of pedagogical approaches to importing the knowledge, science, and art of pharmacotherapy in the care of persons living with mental illness” (9). In this article, we discuss problems and provide suggestions for improving the pedagogy. Much of the content is derived from presentations and subsequent discussion emanating from the annual teaching sessions at the 2004 and 2005 American College of Neuropsychopharmacology (ACNP) annual meetings. Multiple perspectives were represented, including those of a dean (H.A.N.), chair (B.M.C.), training director (S.Z.), students (C.M., P.W., and D.O.), experienced teachers (C.S. and D.F.K.), ACNP training committee chair, and chair of the American Society of Clinical Psychopharmacology (ASCP) Model Curriculum Committee (I.D.G.).
There are multiple reasons for inadequate training of psychiatry residents in psychopharmacology. Today’s residents face numerous and often conflicting demands on their training time. Nowhere are the educational challenges more formidable than in learning psychopharmacology. The realities of clinical practice demand that residents be trained in the latest psychopharmacology treatments. This is best done by expert psychopharmacologists. However, given the rapid advances in neuroscience, a rapid introduction of new medications and changing strategies of treatment, many training programs do not have the time and resources necessary for expert teaching (1).
There also may be inadequate teaching of neuroscience, which is part of the foundation of psychopharmacology education. Among the reasons teaching neuroscience to psychiatrists has historically been a challenge are competing theoretical orientations, time limitations, disparate trainee and teacher expectations, and what is sometimes perceived as a broad gap between basic science and clinical practice (9). Historically, there has also been a bias against those who are in or entering the field of psychiatry as being less interested in science than those going into some other medical specialties (1). In this article, we identify three categories as primary causes of inadequate training in psychopharmacology. Although there is little doubt that there are many other potential impediments to adequate training in psychopharmacology, these three sets of problems are leading candidates for educational improvement in teaching psychopharmacology.
The first set of problems that leads to inadequate psychopharmacology teaching may be the structure of the teaching program itself. Most clinical psychopharmacology teaching is still largely dependent on the personal opinions of, hopefully, astute clinicians (9). Unfortunately, not all clinicians are up-to-date in their knowledge of psychopharmacology. Large lecture formats in which trainees are passive are commonly used for teaching psychopharmacology to resident groups. It is not clear how much information is retained from a lecture format. Small group teaching in which trainees are active participants, whether in seminar or case conference format, are also commonly used as a teaching venue but often focus on the most difficult, treatment-resistant, and complicated patients. It may be difficult for trainees to apply the recommendations for these patients to more typical clinical cases. In any case, teaching must incorporate principles of adult learning, be relevant, emphasize skills as well as knowledge, and prepare residents for the all-important task of continued self-learning throughout their careers.
A second set of problems includes overemphasis of treatment algorithms (2), as well as underappreciation of the life circumstance, psychodynamic and family context, and developmental issues that may be contributing to the clinical picture. In our experience, treatment algorithms, which can be very helpful guidelines for psychopharmacology education, may unduly restrict a trainee’s creative approach to the use of psychotropic drugs (under supervision) or limit the choice of medication. The “art” of prescribing psychotropics is also insufficiently emphasized in psychopharmacology training and requires teaching residents about the broader context of a patient’s symptoms and disorders, rather than focusing only on a DSM-driven symptom checklist (10).
A third category of reasons for poor teaching of psychopharmacology may be insufficient emphasis on emerging neuroscience discoveries of brain function and genes and their correlation with diagnosis of psychiatric disorders and drug response. And, of course, on the opposite end of the spectrum, focused teaching on the “psychology” of psychopharmacology is mandatory (11, 12).
These three categories of obstacles to psychopharmacology education (along with others that may arise for different reasons in individual programs) should be amenable to improvement. Teaching basic psychopharmacology to psychiatry trainees should not be difficult. Elements of good teaching are readily available: plentiful published research; model curricula (13); extensive clinical experience; and available educational resources, such as lectures, videotapes, audiotapes, and handouts (14).
Two leading professional organizations broadly concerned with psychopharmacology, the ACNP and the ASCP, have convened meetings in which senior academicians and psychopharmacology educators discussed the problems and potential suggestions for improving the teaching of psychopharmacology in residency training programs. The most salient suggestions are described below (needless to say, these are based on our pedagogical biases without controlled evidence of effectiveness).
More Time for Teaching Psychopharmacology
Virtually all teachers of psychopharmacology in these two societies agreed that there is insufficient time devoted to teaching psychopharmacology in most training programs. The new Accreditation Council for Graduate Medical Education (ACGME) training requirements should help. These new requirements mandate that training programs teach and evaluate six core competencies: medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. At least four of these six categories contain competencies directly related to psychopharmacology (7).
Developing Clinical Psychopharmacology Competencies
The psychiatry Residency Review Committee (RRC) has mandated that each program teach and assess at least five different types of psychotherapy, one of which involves combined psychopharmacology and psychotherapy. Hopefully, this will lead to more skilled clinicians emerging from our training programs. Whether the RRC should also have an independent requirement for competency in psychopharmacology is a legitimate and timely question (15).
Development of a Core Curriculum
Centralizing the psychopharmacology curriculum to an identified course director is necessary so that there is someone who can receive, integrate, and respond to inquiries, suggestions, and complaints about the curriculum. A centralized structure will also maximize constructive repetition through the entire learning process and, at the same time, minimize overt repetition in the didactics. The entire psychopharmacology curriculum should have a formalized feedback mechanism, conducted at least yearly, so that residents are forced to actively identify areas of potential improvement. Becoming active participants in learning, residents are more likely to value and assert their own educational process.
The first model curriculum in psychopharmacology was developed in the 1980s by an ACNP committee for teaching psychiatry residents (16). This curriculum was followed by the development in the 1990s of a second model curriculum from the ASCP (17), which is now in its fourth edition (18). Certain facets of the ASCP curriculum deserve special mention, including the “why,” “how,” and “what” of running a psychopharmacology program. The core of the curriculum is a series of PowerPoint lectures and case vignettes with questions.
Complete instructions for use of the curriculum, as well as the lectures, are included in the ASCP package (18). Course sequencing issues are also described in Volume 1 (18). Helpful as they are, the PowerPoint presentations would be even more useful if they were more affordable than previous editions (a major issue for some training programs), if they were referenced (many programs are not blessed with “experts” who already know all of the cutting-edge material), and if a mechanism for consultations with national experts was clearly elucidated. In addition, several training directors have suggested the curriculum would be more useful if it were Web-based and intermittently updated and if “model” lectures for each major topic were available on DVD, VHS, or the Web (14). Each of these knotty issues will influence the content and format of the fifth edition.
One promising recent development in the evolution of this psychopharmacology curriculum has been the formation of a partnership between the ASCP and AADPRT (American Association of Directors of Psychiatric Residency Training). A key component of this partnership is a working committee consisting of members of both associations who edit and update the lectures contained in the curriculum; integrate more material on neuroscience, especially with regard to neuropsychopharmacology; improve the pedagogy (helping teachers learn to most effectively use the curriculum); and provide comprehensive competency-based evaluations. A further goal of the committee is to begin to incorporate new technological advances, such as protected Web-based teaching and learning resources.
Experimental and clinical evidence suggest that the phenomena we deal with as psychiatrists (mood, cognition, and behavior) reflect activity of the brain and that psychiatric illnesses are disorders of the brain. Current technologies promise significant advances in the diagnosis and treatment of these disorders, and the next generation of psychiatrists will need to be able to understand and evaluate evidence from new technologies and apply new scientifically based techniques of care. In the foreseeable future, the genetic basis of the risk of illness, type of illness, and likelihood of response will begin to be understood. Similarly, imaging studies will help determine what individual pathology each patient has and, by observing changes in the brain, will help guide treatment. We propose that several essential topics should form a framework for a state-of-the-art core curriculum for all psychiatric trainees so that they are prepared to be competent modern psychiatrists. These include:
These essential elements of training will ensure that psychiatrists understand the scientific basis of the decisions they must make as findings from neuroscience lead to new ways of diagnosing and treating our patients. The field of psychiatry, if it is to remain current and be most effective, must commit greater resources to neuroscience teaching. Relevance needs to be clear to the trainees, and we should focus on neuroscience concepts that all psychiatrists should care about, such as fear/anxiety, mood, and stress effects on the brain. Mindful of the fact that trainees come with a variety of backgrounds, have different levels of interest and preparation, and have different learning skills, we should provide a variety of ways to learn and offer information in multiple, but always clinical, settings. The goal is not to train neuroscientists but to train psychiatrists as clinicians conversant in neuroscience concepts. In fact, in our experience, good prescribing practice grows more rapidly among residents who have had significant training in neurobiology.
Teaching Clinical Practice
Multiple priorities pull at residents, including clinical duties, family and personal obligations, and, finally, educational goals. Generally, residents are eager to fulfill their educational goals, but conflicts with other priorities are common. Unfortunately, educational goals are often long-term endeavors and are frequently overshadowed by immediate clinical and personal obligations.
Another major factor for residents is that they are generally new physicians and often expect themselves to function with full knowledge, despite limited experience. Thus, residents may have the anxiety characteristic of novices, which may contribute to constricted learning. As such, supervision can help residents with clinical issues (e.g., avoiding using therapies with potential benefits) with which the resident does not have personal experience (the old antidepressants being the prime example) (19).
Residents may displace their inherent novice anxiety and conflicting priorities onto their instructors and the quality of their education. With time being precious, residents will often not tolerate inexperienced or nonexpert instructors. Instructors should have a clear understanding of the literature base pertinent to their topic, keep up with current trends and debates in the literature, and be able to analyze the importance and limitations of specific studies—all traits that we expect from good clinicians. Thus, confidence in the lecturer is an important factor residents must possess, as well as an important factor for the course overall.
Clinical experts in psychopharmacology, as well as seasoned psychopharmacological clinicians, should also participate in teaching residents (18). Expert clinicians can provide a practical limitation to what is known in the literature, what is not agreed upon, and what is not known. They may provide the confidence to use the full range of treatment options, including off-label uses and older, well-studied, and efficacious treatments, such as lithium, clozapine, and monoamine oxidase inhibitors (20). Expert clinicians should also have consistent and varied exposure to residents in multiple years and multiple clinical settings to better foster ongoing relationships with residents, and thus facilitate an exchange of information. Occasionally, these relationships may foster residents’ interest in becoming experts in a specific area or even embarking on academic careers, thus expanding the field of clinical experts. Finally, exposure to expert clinicians in different settings provides a degree of repetition necessary for successful learning.
Regardless of their level of expertise, teachers of psychopharmacology should use case-based teaching and must be able to demonstrate the comprehensive formulation of a clinical case. The art of prescribing psychotropic drugs is based not only on a differential DSM-based diagnosis but on knowledge of developmental patterns in childhood, attachment patterns to primary objects, family, sociocultural and interpersonal psychodynamic and behavioral interactions, and adult interpersonal behavior. Teaching must include the roles of stress, comorbid illness, and substance abuse. Basic psychopharmacological information (e.g., starting and maintenance doses, drug interactions and hepatic enzyme function, and side effects) should be taught early in training programs and be repeated throughout the training years. Hard copies of basic information are helpful. Lastly, and perhaps most importantly, trainees must learn to prescribe psychotropic drugs in a comprehensive treatment context that includes various forms of psychotherapy, education, and rehabilitation. That is, we strongly support integration of medication with the complex treatment of every patient (12, 15). This requires the integration of psychopharmacology teaching into all aspects of psychiatric training and educational programs. Supervisors in a clinical case conference should include a psychopharmacologist and a second clinician who can discuss diagnosis and treatment from a nonmedication perspective (10).
Evaluation Strategies and the Use of Tests to Monitor Learning
Pretesting at the beginning of a psychopharmacology course or lecture series may be beneficial to clarify learning goals and expectations. The use of testing at the end of a lecture series may also be beneficial to assess whether learning has occurred. Most psychiatry training programs use the annual Psychiatry Resident-In-Training Examination (PRITE) to assess and monitor knowledge. The PRITE has a subsection on psychopharmacology that can be used as one measure of psychopharmacology knowledge. Ideally, this can be augmented by program-specific written and oral examinations and mock oral-board-type examinations covering both diagnostic and therapeutic competency. But as Louie et al. (8) have pointed out, “more novel measures may need invention when testing more sophisticated psychopharmacological skills.” A good example is the report by Roman and Trevino (21), which discusses clerkship evaluation.
The real test is monitoring actual performance during the clinics and postresidency, but appropriate assessment measures are awaiting development and implementation.
As for resource-poor programs, at a minimum they need at least one “psychopharmacologist” (broadly defined). Many lack even one. In addition, they need a teaching curriculum. Some programs with this problem in the United States have reported improvements in their teaching efforts by adapting the pedagogical resources from the ASCP model curriculum (18).
Lectures and teaching seminars in psychopharmacology must be supplemented by alternative interactive educational sessions. Zisook et al. (22) have discussed in detail the pros and cons of six “nonlecture” methods of teaching.
We also recommend “nontraditional” topics, such as teaching sessions on treatment adherence, ethical issues in pharmacotherapy, pharma-residency training relationships, and combining pharmacotherapy with psychotherapy (23).
In summary, among the many challenges that psychiatry training programs face today, perhaps none is more important than ensuring that psychiatry residents learn to choose and prescribe medication in a scientifically sound manner that is evidence-based, maximally safe, and effective. It is a challenge that can be met, but only with the effort and perseverance it deserves.
Among academic professionals, teachers of psychopharmacology should be acutely aware of the limitations of the teaching base that are compounded by the sabotaging time restrictions on proper care. The concept of “outmoded” psychotropic medications should be abandoned. Trainees should still be taught the use of conventional neuroleptics, lithium, tricyclic antidepressants, and MAO (monoamine oxidase) inhibitors, as well as the use of more recently developed agents (19). A core neuroscience module of 10 to 15 hours should be instituted early in training. Whenever possible, this core neuroscience teaching should be integrated into clinical rotations where issues relevant to patients for whom the residents care can be discussed. There should be opportunities for small and large group learning, and reading and discussion of the literature. For these purposes, a longitudinal research awareness component, including journal clubs, grand rounds, and case conferences, may be most effective. Videotape or teleconferencing can provide students with desired lectures and contacts for teaching programs that cannot support neuroscience teaching. Implementing and maintaining a high quality curriculum will require continued commitment and monitoring by a knowledgeable training director with input from local and national experts. The latter can be achieved through national meetings on training and neuroscience.
Regarding overall organization of lectures, early lectures should be more DSM-IV disorders-specific, while later lectures should be medication class-specific. Residents are expected to care for patients from the beginning of residency training. Being able to understand a complex presentation of a unique patient in an organized diagnostic strategy is beneficial for the novice clinician. Without a working diagnosis, specific treatment strategies are more difficult to develop. Thus, early lectures that focus on DSM-IV disorder-specific treatments will provide an initial framework to understand patients and allow residents to develop confidence in treating patients successfully. Later, with more clinical experience, the intricacies of patients and individualized treatments can be developed. Thus, later lectures focusing on specific medication classes may allow residents an opportunity to develop a more sophisticated understanding of psychopharmacology and how different medications may target unique constellations of symptom clusters in individual patients with complex presentations or comorbid diagnoses.
Repetition is arguably the most important feature of successful learning. Residents should be exposed to different clinical experts with similar areas of interest in order to have reinforcement of basic information, as well as be exposed to some of the intricacies of individualized treatment that may differ among clinicians. Focusing on disorder-specific topics early and medication-specific topics later exposes residents to overlapping material with added levels of complexity across the years of residency. Finally, multiple learning settings, such as didactic lectures, clinical case conferences presented jointly by residents and attending physicians, and clinical supervision, allows an overlap of knowledge acquisition without the boredom of hearing the same lecture again.
Now should be the time to take the following actions:
These measures will not be the total answer, but they are a start. And of course, alternative models that might decrease the likelihood of “below standard” practice postresidency, such as more intensive quality assurance review, may actually be necessary.