Is a nationally available psychopharmacology curriculum feasible, and if so, would it be useful? Although the answers to these questions seem obvious, previous attempts to develop model curricula in psychiatry training programs have generally not been received with much enthusiasm. In a comprehensive review of 43 model curricula in psychiatry covering roughly two dozen topic areas (published or disseminated through organizations since 1985), Wulsin and Kramer (1) reported that only one of these curricula (2) had been used in more than two settings. The single exception, the American Society of Clinical Psychopharmacology (ASCP) Model Psychopharmacology Curriculum (3), has been in various stages of development for almost three decades and has undergone several iterations and updates (4). It includes pedagogy and content, three volumes of text describing the curriculum and how it can be taught and evaluated, and a CD with over 70 presentations in child, adult, and geriatric psychopharmacology. However, despite being described as “the most comprehensive curriculum development process in academic psychiatry” (1) and purchased by several residency training programs (4), the ASCP curriculum remains “more honored in the breach by being ignored than by being used” (5).
Psychopharmacology training was highlighted at the 2005 annual meeting “premeeting” of the American Association of Directors of Psychiatric Residency Training (AADPRT), and representatives of ASCP and AADPRT began a dialogue about the shortcomings and needs in psychopharmacology training and the possibility of working together to meet some of these needs. Over the following year, a partnership and formal contract between these two organizations was forged around the common goal of upgrading knowledge and clinical competencies in this important area. In general, the ASCP was to supply content and AADPRT pedagogy plus some additional neuroscience. Each group agreed that the curriculum would be most useful—and used—if the pedagogy transcended customary modes of teaching based on experts lecturing novices but, rather, incorporated principles of adult learning using technologically advanced, innovative, and interactive teaching methodologies (6, 7). This article describes the development of such a curriculum and results of field trials on its initial implementation.
At the 2006 AADPRT annual meeting, an ad hoc committee was formed to begin working on the psychopharmacology training project. The committee purposely included individuals with ties to the AADPRT executive committee (DG, EB, MJ, SB), the ASCP psychopharmacology curriculum committee (SZ, RB), neuroscience (MJ, SB), problem-based learning (GT), and technological expertise (SB). After initially discussing ways of making the entire ASCP curriculum more user-friendly, web-based, interactive, and adult-learner centered, it gradually condensed its goals into developing one topic that could serve as a model for other topics and be field tested for its feasibility and usefulness. An introductory (postgraduate year [PGY] 1 or 2) schizophrenia presentation was selected for this trial. As a first step, one of the authors (MJ), who had already updated the most recent ASCP curriculum presentation on treatment of schizophrenia, agreed to update the content further, especially by adding more neuroscience content. In addition, he delivered the updated presentation to students and residents at California Pacific Medical Center. The lecture was videotaped to serve as an example of a “master lecture” and provided material for the video-enhanced presentation.
The committee presented a workshop at the 2007 AADPRT annual meeting introducing the schizophrenia module and some of its innovative components. Table 1 lists the major components and suggested uses. The workshop began with a brief demonstration of how this material is traditionally taught (a lecture), and then an alternative lecture format with a video-enhanced slide presentation (which included both embedded video vignettes of the lecture described earlier as well as the capacity to navigate to specific topics or slides rather than simply providing a linear presentation). The highlight of the workshop was a brief vignette from Out of the Shadows, an award-winning video on living with chronic schizophrenia and the effects on the patient and family. This was followed by a team-learning exercise led by one of the authors (GT) that demonstrated a more interactive way the module could be taught.
All AADPRT members who attended the 2007 AADPRT annual meeting workshop on the psychopharmacology curriculum were invited to volunteer for the field test. The programs of six of the committee members and an additional 13 training directors volunteered for the field trial. Participants were told they would receive teaching materials in the late spring to early summer so that the module could be given before January 2008. Volunteers provided contact information and received periodic reminders of the status of the module’s development and expected date of delivery. Unfortunately, the module was not completed and sent to the programs until late September 2007.
All participating programs were asked to administer the premodule test provided; to utilize one or more ways of presenting the didactic information (slides, video-enhanced slides, as an assignment to review in advance followed by problem-based learning [PBL] exercises or discussion, etc.); to consider using the included PBL and team-based learning (TBL) exercises (highly encouraged but optional); to administer the postmodule test provided and e-mail the percent correct data to one of the authors (SZ); and to have the training director or teaching faculty be available for a structured phone interview to evaluate the module.
Each program was sent two CDs, one for instructors and one for residents. The instructor CD contained instructions for use of the module (available from the authors on request) and a tool chest of teaching materials (Table 1). The trainee CD contained a video-enhanced slide set with HTML interface. Programs were encouraged to duplicate the trainee CD for their residents’ use if desired.
Each committee member was assigned one other committee member and two or three other participants for a structured phone interview for evaluation. The questionnaire is available upon request from the corresponding author.
The University of California, San Diego, internal review board exempted the field trial from formal informed consent for dissemination (presentation and publication).
Because of the time necessary to settle permission and copyright issues regarding the Out of the Shadows video vignette, the module was not distributed to programs until late September 2007, creating some curricular scheduling problems for participating programs. Still, all six of the committee members’ programs and eight of the 13 additional programs (14 overall) that had volunteered to participate tested the curriculum by the due date. Of the 14 programs using the curriculum, 13 completed the survey.
Of the five programs that did not use the module, two did not receive it in time to use in the 2007–2008 academic year, one did not recall requesting the module, one had a “communication gap” between the training director and associate training director, and one showed it to a chief resident but did not use it beyond that. At least four of the five plan to use it in the future.
In most cases the module was taught by the training director or associate training director. In two cases it was team-taught by the training director and an additional content expert, and in two cases it was taught by another faculty person.
Most often, this module was given as part of the required curriculum. In one case, the core seminar series had already been given, so the module was provided as an elective for PGY-1 and PGY-2 trainees; more than 50% of PGY-1 and about 30% of PGY-2 trainees attended. In another case, it was required for PGY-1 and PGY-2 trainees, but also given separately as an elective for PGY-3 trainees.
All participating programs had training directors or associate training directors who attended the 2007 AADPRT workshop on the curriculum. Most expressed an interest in trying something new and learning more about adult-centered, interactive teaching.
There was great variability in how the module was taught and which parts were used (Table 2). The most frequently used components were the pre- and postmodule tests (n=12), while none of the programs used the recommended competencies. Most programs also used the assessment scores and nonstructured verbal feedback from participants for evaluations. In one program, the premodule test was given prior to self-study and the postmodule test was administered as a team competition during the seminar. All five of the programs that reported results of pre- and postmodule testing found about a 20% gain in scores (Table 3). Three programs also obtained written assessments.
Residents were uniformly enthusiastic about the module, no matter how it was used. In particular, residents commented on the quality of the lecture material, the inclusion of more neuroscience than they often receive, the PBL/TBL exercises, and the interactive nature of the presentations. Most believed that the Out of the Shadows video added interest and impact, while a few believed that it was unnecessary. Residents from two programs spontaneously commented that this module should serve as the model for their entire didactic curriculum. Instructors also felt positive about the program. Several volunteered to participate in further iterations of this curriculum, and 12 of 13 said they would definitely use it again.
Some respondents believed that the “model lecture” would be even more useful if it were broken into two or more talks, allowing the lecturer, in this case one of the authors (MJ), to provide more case vignettes and personal reflections. There were suggestions for more embedded video vignettes in the presentation, particularly covering phenomenology, aspects of the mental status, and examples of movement disorders. A few respondents requested a follow-up advanced module on schizophrenia spectrum disorders, and several encouraged the committee to develop similar modules on other important disease states, such as mood, substance use, and anxiety disorders.
The majority of respondents (12/13) believed that this type of activity was appropriate for AADPRT and were enthusiastic about further development of similar curricula. At the 2008 AADPRT meeting, the results of this field trial were presented at a well-attended workshop, and the consensus seemed to be for further development, although no one present at the workshop (including the current committee members) volunteered to take a lead role in the next module’s development.
Returning to the initial questions, “Is a nationally available psychopharmacology curriculum feasible, and if so, will it be useful?” the answers are “probably,” “maybe,” and “but.” “Probably” because this project demonstrated that a curriculum can be developed that is exciting, innovative, and informative enough for a wide variety of programs. “Maybe” because no matter how innovative and comprehensive the program is, a substantial number of training programs will not use it, and many others will not take full advantage of its many features. And “but” because it takes an enormous effort—in this case from a large team of educators—to produce the kind of adult-centered learning module that programs will find useful enough to actually implement, and perhaps even more effort to disseminate the curriculum and educate the educators.
We were encouraged that so many programs, 14 of 19, were able to find a place for the module in their curriculum. Most of the programs that did not use the curriculum said they received it too late to use it before our deadline but look forward to using it in the near future. We are not aware of any other “model” curricula that have been as widely used. Our model may have been accepted because the developers of the curriculum were known by the other participants, all participants took the time to attend a workshop on teaching psychopharmacology and demonstrated interest and motivation by volunteering to field test the curriculum, and almost half of the participating programs were those of the committee members.
We were also encouraged that programs used the module in ways that fit their own programmatic needs and resources. No two programs used the curriculum in exactly the same way, and most of the components were used successfully by at least some programs. That was our intention. At the same time, we were disappointed that more programs did not take advantage of a fuller range of the PBL/TBL exercises or make up their own, and only a minority explored the web sites that were provided for more information on “power” teaching and adult-centered learning. Training directors and educators may be too busy to explore novel approaches or future modules may need to make the value of these exercises more apparent. Another possibility is that the amount of time and scheduling complications precluded the use of all options provided by the curriculum. Most programs have their didactic schedule set in advance and were probably able to find only an hour or two to test this novel program, whereas the use of all options offered (lecture, video, PBL, etc.) may have consumed several hours.
That no one explored the suggested avenues of using the module to teach or assess competencies other than knowledge was surprising, especially given the current focus on assessment of the six ACGME core competencies. In future iterations, we may need to be more explicit on how teaching modules can be readily applied to each competency. We still believe that if this can be done effectively, it will only enhance the value and increase the use of such curricula.
The development and preliminary testing of this psychopharmacology curriculum has its problems and limitations. For instance, the number of evaluating programs was small and the validity of the evaluation methodology could be debated. Nevertheless, this was the first attempt to develop a complex, multimodal, nationally available teaching curriculum. It remains to be determined whether the model curriculum format, frequently updated by a group of experts and educators, is the future in psychiatric education. Widely available curricula could be especially advantageous to smaller programs. These programs may not have expertise and resources to provide their residents with state-of-the-art information in all areas (even larger programs may not be able to provide this), but we also have seen examples of large and well-staffed programs that felt positive about this curriculum. Curricula created by national organizations such as AADPRT and ASCP could be generated by experts in several areas, updated frequently, comprehensive, easy to use for nonexperts, easily adaptable to local needs, could make use of new technologies, and be free of commercial bias (8). Future studies of such curricula should include reliable and valid outcome measures and appropriate comparison groups.
It is important to underscore the time it took seven educators to come up with one teaching module—in some cases given as a single teaching session over 1 hour. Each of us had an important role that required hours of preparation and work, a not unsubstantial amount of money was required to acquire rights to the Out of the Shadows video and associated technical support, and a series of conference calls spanning over a year were necessary. In addition, two different workshops were dedicated to the module’s development and implementation, and personal calls were made to all participants for feedback. Although subsequent modules may require less time and effort, there is no doubt that the demands will remain considerable. Despite that caveat, plans are in place to pilot at least one more module, most likely a beginning session on mood disorders that will include a few interested residents. In addition, ASCP is adapting its psychopharmacology curriculum for medical students, family medicine physicians, and possibly psychiatrists in practice.
Simply watching experts select specific medications or suggest psychotherapy modalities on rounds or attending a series of slide presentations is no longer state-of-the-art (9). Rather, emphasis needs to be on residents mastering the large volume of information on how to select and safely use the best treatment options for specific patients under unique circumstances, learning how to apply that information with different patients in a variety of situations and systems of care, problem solving and keeping up with the evolving literature, working collaboratively with other disciplines, and integrating pharmacotherapy with all other applicable therapeutic modalities that are or become available (10). No single modality of training can meet each of these goals, but a series of teaching modules that takes advantage of multiple learning styles, provides up-to-date information, encourages continued learning, and models expert teaching is a good start. Each program should not have to grapple on its own to find the best curriculum possible for its trainees; our future patients may be well served if national experts, working as a team, develop dynamic curricula that all programs can modify and use as best fits their unique needs. To accomplish this objective, specialty organizations like AADPRT and ASCP will need to take on leadership roles, and financial reimbursement and/or academic promotion for key contributors must occur. Finally, support from other key organizations such as APA and the National Institute for Mental Health would also go a long way to facilitate the effort. The results of this field trial provide some data that the goal of developing a state-of-the-art psychiatry curriculum may be more feasible than heretofore imagined, but not without considerable effort and dedication.
The authors thank the following psychiatric residency programs for their participation in this pilot program and for taking the time to provide verbal evaluations of the curriculum: Austin Medical Education Programs; California Pacific Medical Center; Cleveland Clinic; Duke University; Hennepin County Medical Center; New York University; Saint Elizabeth Medical Center; University of Buffalo; University of California, San Diego; University of California, San Francisco; University of Massachusetts; University of Michigan; University of Nebraska; and Wayne State University. The authors also thank Rick Brandt of Packetrat Communications for his expert technical consultation and development of the video-enhanced slide set with HTML interface.
Disclosures of Academic Psychiatry editors are published in each January issue. Drs. Benjamin, Goldberg, and Thrall stated no competing interests.