Academic Psychiatry 25:90-97, June 2001
© 2001 Academic Psychiatry
How Should We Teach Psychopharmacology to Residents?
Results of the Initial Experience With the ASCP Model Curriculum
Ira D. Glick, M.D.,
David S. Janowsky, M.D.,
Sidney Zisook, M.D.,
R. Bruce Lydiard, M.D., Ph.D.,
Jessica R. Oesterheld, M.D.,
Nicholas G. Ward, M.D.,
James Ellison, M.D.,
James Halper, M.D.,
P. Murali Doraiswamy, M.D.,
David W. Preven, M.D.,
Peter Ross, Executive Director, ASCP and
Donald F. Klein, M.D.
Mr. Ross is Executive Director at the American Society of Clinical Psychopharmacology, P.O. Box 2257, New York, NY 10116. Dr. Glick is at the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA. Address reprint requests to Dr. Glick at the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94121.
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ABSTRACT
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There is now more information to assimilate in clinical psychopharmacology and newer ways to acquire this information. Educational materials should be designed for and targeted to meet the diverse needs of such groups as medical students, psychiatry residents, clinical practitioners, industry and federal scientists, and clinical research organizations. As a starting point, the authors developed, in 1997, a model curriculum for psychopharmacology residency programs. The curriculum consists of 1) overview, 2) learning and educational objectives, 3) what and how to teach, 4) how to evaluate, 5) how to organize a psychopharmacology program, and 6) an investigative psychiatry curriculum. There are 31 lecture outlines and hard copies of 1,500 slides, comprising basic and advanced courses. A 1-year follow-up evaluation of users' experience found that 62% rated the curriculum, to varying degrees, as improving the teaching of psychopharmacology in their programs.
Key Words: Pharmacology • Model Curricula • American Society of Clinical Psychopharmacology (ASCP)
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INTRODUCTION
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Compared with other areas of psychiatry, the science and practice of psychopharmacology arguably changes most rapidly. There are three key issues affecting the teaching of psychopharmacology: 1) rapidly advancing knowledge and availability of new medications; 2) increasing ways to access knowledge; and 3) diverse curriculum and student needs (for example, how much to focus on neuroscience vs. clinical practice issues). At the same time, we must recognize the realistic circumstances under which clinical psychopharmacology is currently carried out. In other words, with 15 minutes to evaluate a new patient or 5 minutes to follow up, it isn't going to work.
For the last two decades, as the knowledge base has expanded, the development of a model curriculum in psychopharmacology has been encouraged from three principal sources. The first is the AADPRT (American Association of Directors of Psychiatric Residency Training); the second, department-of-psychiatry chairs; the third is the large number of training programs, which either did not have an adequate number of teachers (of psychopharmacology) and/or did not have adequate resources to mount an adequate program. To answer this need, a curriculum was prepared in the early 1980s under the auspices of the American College of Neuropsychopharmacology (ACNP;1). In the mid-1990s, this curriculum was completely redone and updated by a committee of The American Society of Clinical Psychopharmacology (ASCP;2). It was specifically designed for psychiatric residency programs, with the needs of training directors and teachers in mind.
Cognizant of the importance of revisions being completed on an "as-necessary" basis (as the field changes), the ASCP is now in the process of revising the 1997 version. As with the previous edition, it is being constructed by training directors, teachers of psychopharmacology, and, for each specific topic area, experts in the given area. The aim is to provide as much as possible (except for the teachers and the curriculum time), in one package, what is needed to teach modern psychopharmacology to psychiatric residents. The intent of the curriculum is to provide a "smorgasbord" from which individual teachers pick and choose what they feel is best for their individual program.
The curriculum is divided into three key parts: the first is a teachers' guide, consisting of an introduction to the curriculum on how to organize a psychopharmacology program. It contains of an overview, educational objectives, suggestions on what to teach and how to teach it, and how to evaluate the success of one's teaching. The second part consists of the content of the lecture series: 1) the lectures; that is, hard copies of illustrative slides, accompanied in some cases by 2) lecture outlines, and 3) case vignettes. (Actual slides [1] can be ordered from the ASCP). The third part consists of a series of appendices, comprising rating scales and additional teaching material, such as a list of lectures available on videotape, suggestions for texts, and so forth (see below).
In this article (and in part in the original document [2]), we describe the theory and practice of setting up a model curriculum, how to implement the curriculum, and the "do's and don't's" as reported by those who have already used it (3). Our aim here is not to claim great success of this project, but rather to share the process, especially the ongoing feedback and revision aspects (which very few model-curriculum authors have done).
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METHODS
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The psychopharmacology model curriculum was developed, and this paper written, by a committee of the ASCP. The committee is composed of experienced, expert psychopharmacology teachers (and clinicians), mostly with major academic appointments, one recently-graduated resident (PMD) and the Executive Director of the ASCP (PR). Before the ACNP had published the first model curriculum, Carl Salzman, M.D., Professor of Psychiatry at Harvard Medical School, had done an extensive survey of psychopharmacology training in the United States. We reported gaping holes in knowledge transfer and teaching resources (4). In 1996, before deciding whether or not to expend the time, effort, and money necessary to do a major revision of the ACNP Curriculum, we called residency training directors at 12 different training institutions to ask them how, and if, they were using the earlier edition. At this juncture, virtually none were using the ACNP Curriculum, although they were almost unanimous in asserting the need for such a curriculum. The major deficiency of the earlier edition, they felt, was that, although it suggested what should be taught and where the material required might be found, it was out-of-date. Also, the consensus was that without the actual lecture material, the Model Curriculum would not be used by their staff, whom, they felt, were unable or unwilling to collect cutting-edge material themselves. With that information in hand, we decided that the effort was worth it. We decided that the most important element was the revision of the individual lectures. The second-most-important component was the focus on how to do individual supervised teaching in inpatient and outpatient settings. In short, the needs were 1) the knowledge base, and 2) how to apply it to diverse clinical situations. The curriculum goes into detail about how to address these needs. With regard to the teaching aids, we canvassed expert psychopharmacologists (most, but not all, were ASCP members) and compiled an extensive series of teaching aids, lecture outlines, and hard-copies of slides. The last, to the best of our knowledge, is the most extensive collection of slides ever developed for training in the field of psychopharmacology.
The committee was coordinated by a member of the original ACNP team (IDG), with responsibilities divided among members for revising and updating the teacher and training-director guide, updating the lecture series, and creating the extensive appendices aimed at supplying many of the curriculum materials necessary for both teachers and students. Even so, the most that we could accomplish was to provide a "skeleton" or "framework" for a curriculum. The most time-consuming job was creating the hard copy of 32 separate lectures—a job coordinated in the 1997 version by Nick Ward, M.D., a psychopharmacologist and full-time faculty member at the University of Washington, with the help of ASCP experts selected for each lecture topic; that is, psychosis, depression, and so forth. The lecture hard copy was compiled from these teacher–psychopharmacologists. After every lecture was assembled, it was peer-reviewed for accuracy and usability by another committee member. A final review for consistency was done by the lecture series coordinator.
The project was funded mostly with resources and tools of the ASCP and its members. It took approximately 8 months to complete. Committee members (as well as those who developed lectures) gave their time voluntarily and without compensation. To a great extent, the project was fueled by the modest amount of positive feedback the original ACNP Committee received (personal communication; IDG and DSJ). Early on, Lilly Pharmaceuticals provided an unrestricted educational grant to support ASCP administrative costs. Initially, the curriculum was sold for $500 per copy (and later for $600).
Curriculum Content
In the preface, we describe how and why the curriculum was developed and provide our rationale for its use. We then describe, in some detail, what we consider to be a coordinated and integrative organization of a psychopharmacology training program. To this end, we put special emphasis on the relationship of research to training by detailing how they interrelate.
In the second part of the curriculum, we provide an overview of the required educational objectives, including specifically what knowledge and skills we believe ought to be possessed by the resident at the conclusion of his or her training.
Next, we get into the "nitty-gritty" of what and how to teach (Table 1). The first component of this material is a multimodal didactic program for each of the courses over the 4 years of psychiatric residency. The preferred organization of this set of courses includes 1) a "crash course" in the PGY-I and -II years; 2) a PGY-II basic or introductory course; and 3) a PGY-III (or -IV) advanced course. The crash course stresses the basics of inpatient and emergency room psychiatry, emphasizing safety and drug interactions in particular. We have added other course ideas, such as a suggestion for a neuroscience course and a journal club. The structure of each lecture is covered, including general concepts, and a lecture template for each topic is included. Specific lecture topics include antipsychotics, antidepressants, antianxiety agents, mood stabilizers, and a focus of combining medication with psychosocial interventions.
Table 2 and Table 3 provide the list of lecture topics for the basic (PGY-II) and the advanced (PGY-III) course. By way of example, at the end of this article, we provide a sample lecture outline with hard copies of slides. We also describe how to use the lecture materials. The key issue (our psychopharmacology–teacher experts argued) was to supply a core group of slides for each topic—from which each local teacher could build a lecture. Therefore, the lectures and slides provided came from the files of expert psychopharmacologists, who teach psychopharmacology at their own institutions and nationally, and obviously reflect what these experts consider to be important. They deserve modification and addition of details by faculty members who will give a specific lecture at a local program. Therefore, they may be used, at one extreme, as a total package or, at the other extreme, by inclusion of one or two slides. There was little support in the Committee for use of "group discussion" in teaching the basic topics in most lecture series, but we do advocate interactive teaching. We did not provide either what has been referred to as "key points," or references for each lecture because we assumed lecturers would assign the recommended texts (which provide both key points and extensive references).
To complement the courses and lectures, we cover subjects such as the mechanics of the development and organization of a literature review seminar (journal club), as well as how to set up case conferences and relate them to lectures. In other words, group discussion formats can complement the lecture formats. A special section has been developed describing the use of computers in psychopharmacology, along with information on how to find helpful websites. There is a section on the use of rating scales and techniques relating to how ratings are done. This part of the curriculum also includes sections on child and adolescent psychopharmacology and geriatric psychopharmacology. Here, we include material needed for lectures on these subjects, rating scales in child and adolescent psychopharmacology, a case study illustrating teaching points made in the lecture, and a curriculum and readings that underlie the child and adolescent and geriatric teaching modules.
Also discussed are techniques of supervision, including clinical-mentorial teaching and the use of selected case material. Psychopharmacology supervisory techniques are covered, as is how these techniques can vary among different settings, such as psychopharmacology clinics, inpatient units, and emergency rooms, and how all of this is related to didactic material. Annotated lists of recommended psychopharmacology texts, journals, and newsletters are also included.
The section on what and how to teach includes a neuroscience lecture section that provides the basis for more clinically focused teaching and a section detailing how psychopharmacology units, as they are now functioning in outpatient clinics, can best be related to a didactic program.
The final part of the Curriculum details how to evaluate the teaching and the learning of psychopharmacology. We discuss the use of formal examinations and make several suggestions concerning these, including the use of the PRITE (Psychiatry Residents-in-Training Examination). We describe how charting patterns can be a sensitive and accurate indicator of how much and how well a trainee is learning. We present examples of, and rationale for, forms used for 1) evaluation of supervisors; 2) evaluation of the program; and 3) supervisors' evaluation of the trainee. The section concludes with a discussion of accreditation issues, and how one manages to cover all the above material in 4 years.
It should be noted that we stressed the need for a psychopharmacology coordinator to coordinate the total psychopharmacology track, that is, to avoid overlap of didactic material and to provide continuity among courses. Some have viewed this suggestion as promoting lack of integration of psychopharmacology with the rest of the curriculum (1). We disagree, and we suggest that the coordinator perform (on a yearly basis) a number of tasks that foster psychopharmacology integration with the rest of the curriculum (1).
Appendices
In addition to the above instructional materials, a set of appendices has been developed. The appendices provide the teaching materials for the didactic program. Appendix A is the lecture series, including a basic course for beginning residents (see Table 2). Lectures include basic principles of pharmacodynamics, pharmacokinetics of psychotropic drugs, psychopharmacology of bipolar disorders, and use of antipsychotic and antidepressant treatments. We also have provided lectures on electroconvulsive therapy (ECT), sleep disorders, the pharmacotherapy of violence, the diagnosis and pharmacologic treatment of aggression in elderly patients, and traumatic brain injury. The curriculum for advanced courses for PGY-III and PGY-IV residents is shown in Table 3.
Lecture outlines and hard copies of slides provide the material for most of the didactic teaching. They may certainly be used as the teacher wishes, but our suggestion is for them to be used as the starting point for teachers who may, if they wish, also delete, modify, or add some of their own slides. Some teachers have found that providing the hard copy of the slides as handouts for their students is very helpful (J. Oesterheld; 1999, personal communication). In order to be sure we have created a workable model, we provided our lecture outline and hard copies of slides on adolescent/child psychopharmacology to a teacher who had never taught this topic and asked him, using only this material, to teach the subject to groups of residents. The teacher and the students all felt that it had been effective (Penn JV, Holden P, and Hendren R, 1998, personal communication). We suggest that the use of the slides would work even better if the teacher were to develop additional slides of his or her own keyed to his or her own preferred methods of teaching. Where the faculty is less experienced, our slides may prove to be the single most valuable part of the entire curriculum.
Appendix B describes the rating scales commonly used in psychopharmacologic practice, such as the Clinical Global Impression (CGI), the Hamilton Rating Scale for Depression (Ham-D), and so forth. Appendices C and D list other useful professional books and journals in addition to our recommended list. Appendix E lists consumer-oriented books and organizations. Appendix F provides the complete set of actual evaluation forms (described in the text) aimed at determining how well trainees have learned, as well as forms allowing the trainees to evaluate the program and their supervisors. Appendix G presents an investigative psychiatry course specifically aimed at teaching residents how to evaluate the literature by, in part, doing their own research project and presenting it for peer and faculty critiques. Appendix H provides information on how to acquire videotaped lectures given by expert clinicians. These come from the Worthington Master Clinician series; they can be purchased at an additional cost beyond the basic cost of the curriculum. Although now 5 years old, they are still useful teaching tools. Future editions likely will include an expanded array of audiovisual and multimedia teaching materials, as well as references to relevant interactive sites and Web pages with "Meet the Experts" chat rooms.
Follow Up Evaluation
As mentioned earlier, a previous version of this curriculum was developed in the mid-1980s by a committee of the ACNP consisting of teachers of psychopharmacology at four different medical schools. That early curriculum was distributed gratis to all of the members of the ACNP and to the chairs of all of the psychiatry departments in the United States. It was translated into Spanish, Japanese, and several other languages. A follow-up evaluation (5) revealed that in many institutions in the United States, it had never been opened. When the curriculum had been forwarded to a training director or when the ACNP member was an integral part of a given training program, it was more likely to be used and was judged both in the survey and by informal networking, almost without exception, to have improved teaching. Unfortunately, whether because there was no perceived need by experts in outstanding teaching programs, and/or because it was improperly marketed (6), that first curriculum never received the widespread use we believe it should have had.
One year after publication of the ASCP model curriculum, we discussed doing a revision. We decided not to do it without systematic feedback. Our preference was to do the feedback "teacher-to-teacher." We had no additional financial resources for a large-scale evaluation, and the committee members had limited time. Accordingly, in order to learn from history (and our "customers"), in 1998, eight members of the committee did a follow-up telephone evaluation survey of 21 of the 41 psychiatry residency training programs that (by then) had purchased the curriculum for the 1997–98 academic year. An open-ended questionnaire was designed to tell whether 1) the curriculum was indeed received; 2) it was used for training; 3) if not used, why not; 4) if used, how, and which parts; and 5) ways to improve it. Finally, we asked respondents to rate 6) whether and 7) how much the model curriculum had improved teaching, compared with the previous year, before receiving the curriculum. The interview contacts were the departmental chair and/or training director. Depending on the relative strength and development of the training program, both differing "amounts" and "specific areas" of the curriculum were used. For example, some programs used "all of it," whereas others, which were highly staffed with a surfeit of experts in different fields, used "certain ones of the lecture series," such as, for example, the lecture on body dysmorphic disorder.
Each committee member interviewed two or three programs. To improve response rate, we attempted to match the committee member with the program; that is, when he or she knew the training director or chair. This, of course, may have introduced positive bias, but it also encouraged frankness. Programs surveyed included those with very sophisticated and complete programs, as compared with the other extreme of those "just getting started." Data were collated and analyzed by the committee chair (IDG), but no statistical analysis was done because of the small sample size. On the other hand, with great perseverance, we were able to get a 100% response rate by persistently calling the programs. Where detail was lacking and/or the negative affect was "very strong," follow-up interviews were done by the original interviewer and/or the committee chair.
Nine of 21 (43%) of the programs surveyed were "very satisfied," and had used much or most of the curriculum. Four of 21 (19%) were "satisfied"; this was a group who believed that they already had a good program; therefore the curriculum was used less, that is, to varying degrees. Five of 21 (24%) of the programs surveyed reported that they had not yet had time to look at the curriculum, or they hadn't received it, or it had "gotten lost somewhere in the department." Three of 21 (14%) of the surveyed programs reported that they did not use the curriculum much and felt that it was not useful. The primary problem for the last group seemed to be that there was not enough detail explaining how to proceed. That is, these respondents felt overwhelmed by the sheer size of the curriculum or felt that it wasn't user-friendly enough for them to begin to incorporate it into their courses. Of the 16 programs who affirmed they had gotten it, reported they were using it, and responded to the question "Did it improve teaching over the previous year?" 12 reported an increase of 1–3 points on a 10-point scale, and 3 reported no change (one program rated itself as a 10 on the 10-point scale before and after using it, but said they were "pleased with it"). Mean improvement was 6.4 on a 10-point scale. Other suggestions for improvement deriving from the survey included 1) updates (at least biannually); 2) computerized slides; 3) a website; 4) problem-based learning modules; 5) new lecture topics; 6) a list of "key points;" as well as 7) reading and references for each lecture; and 8) making the lecture outlines more clinically-, rather than neurobiologically-based. We discovered that the lecture hard copy was being used in four ways: 1) the teachers adopted it "en masse" as we wrote it; 2) or integrated it with their own materials; 3) or used it as a handout; or 4) gave it to the residents and co-taught it with one of them.
Using the results of this survey, we are preparing a newer version of the model curriculum (Table 4). In part, we have developed a new and more user-friendly table of contents. We are including an introductory letter describing, in considerable detail, how to use the curriculum. We now are offering personal consultation by committee members to subscribers, providing suggestions already used by successful programs, of ways to maximize the benefits provided by the curriculum. A 6-month follow up of four programs that had not known how to use it (for whom we provided consultation by phone), found increased use (as the new curriculum was being introduced). By way of example, we "walked" one program through setting up a lecture series.
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TABLE 4. Contents and organization of the revision of the 1997 American Society of Clinical Psychopharmacology (ASCP) Model Curriculum
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Other criticisms that are being attended to include 1) updating the slides and rating scales; 2) putting slides in PowerPoint and providing a CD-ROM of PowerPoint files; 3) providing an index for the lecture material; 4) providing outlines for each lecture; and 5) adding new lectures, including case vignettes for each lecture. The curriculum has not covered in much detail issues such as 1) the split between biological and psychosocial models; 2) the future etiologic models in the field; 3) experimental biological treatments; and 4) whether psychopharmacology should be a subspecialty of psychiatry.
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SUMMARY AND CONCLUSIONS
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The ASCP is offering an evolving model curriculum for teaching psychopharmacology in psychiatric residency programs. This curriculum is not only a guide designed to provide and organize materials for a teacher to teach, but a document that provides the materials necessary to keep the program current with respect to psychopharmacologic training (especially important because practice guidelines have had only limited impact on clinical practice [7]). From our small follow-up study, we know that the curriculum can be effective in improving the teaching of psychopharmacology in psychiatric residency programs in which it is used. Much needs to be done to assess this curriculum and the general methodology of teaching someone else's lecture and/or course. Formal evaluation with comparison groups should be done after the next edition is published.
Likewise, further efforts need to be made to integrate the curriculum into broader use in the training programs that need it. In this context, two committee members (DP and SZ) presented parts of the model curriculum at the last three meetings of the AADPRT. We are now in the early stages of the process of co-developing and distributing the curriculum with AADPRT (C. Chan, May 2000).
As mentioned, we are also working on updating and expanding the Curriculum for release in 2000. All current material has been reviewed and, where necessary, updated, revised, or replaced. We have prepared slides in an electronic format (PowerPoint), as well. Obviously, the curriculum cannot provide the "critical thinking skills" necessary for good clinical psychopharmacological practice. In the new revision, we have included "PBLs" (problem-based learning items) from Joel Yager, M.D., that begin to address this issue. Also, good teachers can model critical thinking by their attitudinal stance toward the content of the lectures. We expect to modify the curriculum for specific target audiences, such as medical students, pharmaceutical industry personnel, non-psychiatrist physicians, and other mental health workers, for example, psychiatric nurses and others. The overarching aim is to improve the teaching–learning process in psychopharmacology in order to improve clinical care.
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REFERENCES
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- Dubovsky S: A Model Psychopharmacology Curriculum for Psychiatric Residency Training Program Training Directors and Teachers of Psychopharmacology (book review). Acad Psychiatry 1999; 23:185-186[Free Full Text]
- Glick ID, Doraiswamy PM, Halper J, et al: The ASCP Model Psychopharmacology Curriculum for Psychiatric Residency Programs, Training Directors, and Teachers of Psychopharmacology. The American Society of Clinical Psychopharmacology, Inc., New York, NY, 1997
- Hilty D: Workshops and Courses for the 1999 Annual Meeting. AAP Bulletin, Summer 1999, p 6
- Glick ID, Janowsky DS, Salzman C, et al: A Model Psychopharmacology Curriculum for Psychiatric Residents. Nashville, TN, The American College of Neuropsychopharmacology, 1984
- Glick ID, Janowsky DS, Salzman C, et al: A proposal for a model psychopharmacology curriculum for psychiatric residents. Neuropsychopharmacology 1993; 9:1-5[Medline]
- Rush AJ, Mohl PC: The top 10 reasons for psychopharmacology supervision. Acad Psychiatry 1996; 20:238-240
- Jaffe SL, Yager J: A pilot study of a district branch-based educational intervention: awareness and reactions. Acad Psychiatry 1999; 23:9-13[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
