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Committing to the Scientific Basis of Psychiatry: Implications for Training and Educational Research

The recent Institute of Medicine (IOM) report affirmed the scientific basis of psychiatry, calling for vigorous efforts to increase the numbers of patient-oriented investigators in our field and to enhance the overall scientific knowledge and preparation of psychiatrists-in-training (1). Authors of the IOM report specifically recommended that the American Board of Psychiatry and Neurology and the Psychiatry Residency Review Committee require patient-oriented research literacy as a core competency. As a corollary, all residency training programs should teach and assess critical appraisal skills (1). Residencies should adopt curricula encompassing topics fundamental to evidence-based medicine, such as scientific design and methods, problem defining, searching, evaluating, and application of evidence to state-of-the-art clinical practice (2). Finally, psychiatry training should inculcate the capacity for practice-based learning, one of the six core competencies for residents as defined by the Advisory Group of the Accreditation Council for Graduate Medical Education (ACGME) (3).

Four related concepts, each with slightly different implications for psychiatric training, have now been introduced: research literacy, critical appraisal skills, evidence-based medicine, and practice-based learning. The following working definitions might be considered. Research literacy, as articulated in the IOM report, entails the ability to assimilate emerging theoretical knowledge about biology and empirical information relevant to a given set of symptoms and corresponding risk factors or treatments (1). Critical appraisal enables the application of certain rules of evidence and the laws of logic to clinical, investigative and published data and information in order to evaluate their validity, reliability, credibility and utility (4). Skills in critical appraisal should assist readers to identify the validity of scientific design and strength of results, and these are being actively taught as one component of evidence-based medicine in many medical schools (5–9). Evidence-based medicine is a scholarly field—a larger process that also requires an ability to ask focused questions on diagnosis, prognosis, interventions, ethics, and economics beginning with analysis of a clinical situation, retrieval of best evidence, and, crucially, integration of that evidence into clinical care. As such, this field necessarily involves an understanding of epidemiology, quantitative issues (e.g., statistics pertaining to relative risk reduction, absolute risk reduction, confidence intervals, etc). This is a systematic process, in that it is asserted, can be taught and practiced by clinicians at all levels of seniority, and can promote teamwork and self-directed and life-long learning (10). Practice-based learning as a domain of basic competence for the modern physician incorporates skills of review, analysis, and assimilation of scientific evidence (3). These linked endeavors in residency training serve to affirm, anchor, and advance the scientific basis of the field of psychiatry.

These four new concepts represent vitally important initiatives and areas for educational research that we at Academic Psychiatry strongly support (11, 12). Consistent with a commitment to scholarly rigor, novel educational techniques that are included in these initiatives should undergo scientific scrutiny.

Few data exist on the comparative efficiency and effectiveness of various methods for teaching these four skill areas, however. Determining educational effectiveness, despite the very real challenges to educational research, must become core to the mission of any university and college (14). We have little knowledge of what programs have perceived or experienced as barriers, if any, to integrating these initiatives into residency training and how these might be overcome. Even though teaching evidence-based medicine is formally taught to residents in other specialties (15, 16), we understand little about the optimal approaches to teaching research literacy, critical appraisal, evidence-based medicine, and practice-based learning in psychiatry or other fields of medicine (17, 18). We know little about what, how, and in what settings research literacy is currently taught in psychiatry. At another level, we also know little about the ability of the psychiatric workforce to evaluate the literature critically. How often do psychiatrists conduct literature searches and critically read papers as opposed to relying on global impressions? Overriding these issues is the observation that information on outcomes—including clinical outcomes—of teaching research literacy across fields of medicine is very limited.

To this end, we suggest that it is essential that we develop meaningful and reliable methods for evaluating research literacy, critical appraisal skills, evidence-based medicine, and practice-based learning and for studying related educational initiatives (19–20). Committing to the scientific basis of the field of psychiatry also entails a commitment to the enhanced rigor of our educational programs, practices, and related research endeavors.

REFERENCES

1. Institute of Medicine: Research Training in Psychiatry Residency: Strategies for Reform. Washington, DC, National Academics Press, 2003
2. Evidence-based Medicine Working Group: Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268:2420–2425[Abstract/Free Full Text]
3. Accreditation Council for Graduate Medical Education: www.acgme.org
4. Neufeld VR, Olsen RE, Lindberg DAB, et al: Subgroup report on critical appraisal skills: the application of the scientific method. J Med Educ 1984; 59(supp):161–167
5. Ghali WA, Saitz R, Eskew AH, et al: Successful teaching in evidence-based medicine. Med Educ 2000; 34:18–22[CrossRef][Medline]
6. Barzansky B, Etzel SI: Educational programs in US medical schools. JAMA 2003; 290:1190–1196[Abstract/Free Full Text]
7. Finkel ML, Brown HA, Gerber LM, et al.: Teaching evidence-based medicine to medical students. Med Teach 2003; 25:202–209[Medline]
8. Hunt DP, Haidet P, Coverdale JH, et al: The effect of team learning in an evidence-based medicine course for medical students. Teach Learn Med 2003; 15:131–139[CrossRef][Medline]
9. Holloway R, Nesbie K, Bordley D, et al: Teaching and evaluating first and second year medical students’ practice of evidence-based medicine. Med Educ 2004; 38:868–878[CrossRef][Medline]
10. Rosenberg W, Donald A: Evidence-based medicine: an approach to clinical problem solving. Br Med J 1995; 310:1122–1126[Free Full Text]
11. Bogenschutz MP, Roberts LW: Preparing the next generation of psychiatric researchers. Acad Psychiatry 2001; 25:2–3[Abstract/Free Full Text]
12. Roberts LW, Bogenschutz MP: Preparing the next generation of psychiatric researchers: a story of obstacles and optimism. Acad Psychiatry 2001; 25:4–8[Abstract/Free Full Text]
13. Carney PA, Nierenberg DW, Pipas CF, et al: Educational epidemiology: applying population-based design and analytic approaches to study medical education. JAMA 2004; 292:1044–1050[Abstract/Free Full Text]
14. Grimes DA: Introducing evidence-based medicine into a department of obstetrics and gynecology. Obstet Gynecol 1995; 86:451–457[CrossRef][Medline]
15. Green ML: Evidence-based medicine training in internal medicine residency programs: a national survey. J Gen Intern Med 2000; 15:129–133[CrossRef][Medline]
16. Hatala R, Guyatt G: Evaluating the teaching of evidence-based medicine. JAMA 2002; 288:1110–1112[Free Full Text]
17. Coomarasamy A, Taylor R, Khan KS: A systematic review of postgraduate teaching in evidence-based medicine and critical appraisal. Med Teach 2003; 25:77–81[CrossRef][Medline]
18. Fritsche L, Greenhalgh T, Falck-Ytter Y, et al: Do short courses in evidence-based medicine improve knowledge and skills? Validation of Berlin questionnaire and before & after study of courses in evidence-based medicine. Br Med J 2002; 325:1138–1141
19. Ramos KD, Schafer S, Tracz SM: Validation of the Fresno test of competence in evidence-based medicine. Br Med J 2003; 326:319–321[Abstract/Free Full Text]
20. Jarvis RM, O’Sullivan PS, McClan T, et al: Can one portfolio measure the six ACGME general competencies ? Acad Psychiatry 2004; 28(3):190–196[Abstract/Free Full Text]

This article has been cited by other articles:

				J. H. Coverdale, L. Weiss Roberts, and A. K. Louie Teaching Evidence-Based Psychiatry to Residents and Fellows: Developing the Curriculum Acad Psychiatry, November 1, 2008; 32(6): 453 - 457. [Full Text] [PDF]

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