Academic Psychiatry 29:113-115, June 2005
© 2005 Academic Psychiatry
Imparting the Knowledge, Science, and Art of Psychopharmacology: Thoughts on Educational Research Questions
Alan Louie, M.D.,
Laura Weiss Roberts, M.D., M.A. and
John Coverdale, M.D., M.Ed., FRANZCP
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INTRODUCTION
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This special issue provides a variety of useful perspectives on teaching psychopharmacology. These perspectives are proffered by seasoned and dedicated educators, with specific expertise in the area of psychopharmacology, and they have outlined valuable insights, example curricula, and model programs that will be especially worthwhile for our readership. In the development of this collection, however, we were struck—as were the authors of our commentaries in this issue—by the general lack of empirical studies of pedagogical approaches to imparting the knowledge, science, and art of pharmacotherapy in the care of persons living with mental illnesses.
Educational research in all areas of psychiatry remains, unfortunately, in its infancy, and the teaching of psychopharmacology is a case in point. Some investigators obtain student satisfaction surveys or self-rating of knowledge, but randomized, controlled trials of educational interventions in any area of academic medicine are scarce. There are many financial, political, and ethical barriers to such research—suffice it is to say that if opportunities and funding are limited, we must pick our research questions carefully before we invest in their implementation.
In this editorial, we reflect on educational research questions that might derive from the perspectives and commentaries in this issue. We hope that this modest and limited exercise will stimulate thought and empirical research. We look at educational research questions relating to fund of knowledge, critical thinking and appraisal, and clinical judgment. We view these as beginning, intermediate, and advanced skills in psychopharmacology, respectively, and, at each level, we explore research questions with particular emphasis on novel outcomes measures.
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Fund of Knowledge, The Beginning Resident
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At first blush, one might think that teaching psychopharmacology could be readily studied. One asks students to learn various facts: drugs, doses, side effects, indications and the like, and then they are objectively tested by multiple-choice questions (MCQs). The psychometrics of MCQ, as found on the Psychiatric Resident in Training Exam or any typical pre- and post-CME test, have been well analyzed. Left to research is finding better techniques for students to acquire psychopharmacologic facts and improving their scores on MCQs. Fun strategies that more actively engage residents include the use of games to teach these facts (1). Before expending much energy in this direction, however, perhaps one should research the relationship between database acquisition and clinical competence. What is being measured with these MCQs? More sophisticated questions require manipulation of facts and bring them to bear on clinical vignettes, but how much progress has really been made in truly assessing higher levels of thinking such as problem solving, analysis, and the synthesis of information (2), as opposed to memorization? To answer this, one needs some gold standard metric of clinical problem solving (3, 4). Defining a postgraduate rubric and metric for psychiatry would be valuable research and would help residencies teach toward problem solving—and not mere memorization.
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Critical Thinking and Appraisal: The Intermediate Resident
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Evidence-based medicine (EBM) may be one tool for teaching critical thinking and appraisal skills. Evidence-based medicine teaches residents to be critical in each of five steps: 1) identifying clinical problems from individual patient scenarios, 2) searching the literature, 3) analyzing clinical studies, 4) applying the approach to the case at hand, and 5) evaluating effectiveness and efficiency of this process. Residents learn how to find the most scientifically rigorous studies, preferably randomized, placebo-controlled studies with narrow confidence intervals or systematic reviews . With enough of these studies, one attempts to construct treatment algorithms and, then, best practice guidelines. Though the approach seems sensible, little evidence currently proves that teaching EBM improves practice behaviors (5–7), and, as evidenced in this special issue (8, 9), the use of algorithms in teaching psychopharmacology has its supporters and detractors. Several research questions await investigation in this area.
While teaching EBM and critical reading of the literature are laudable and a suitable subject for educational research, some warn that we must not lose sight of our goal to teach residents how to think like psychopharmacologists and not just how to critically read the literature written by psychopharmacological researchers. Mastery of how to think like a psychopharmacologist, about underlying mechanisms of drug actions and their interrelationships with disease states, is required because every patient scenario deviates from the optimal circumstances in published trials, which cannot necessarily be generalized to the real world, causing a gap between knowledge and practice. Thus, EBM leaves us with ambiguity when faced with the uniqueness of the individual patient (10).
Evidence-based medicine provides us with knowledge that has a probabilistic quality. Perhaps this suggests that one should not measure individualized outcomes after teaching EBM. In other words, the effects of teaching should not be sought in individual cases but rather in the effects across a resident’s full caseload. For example, a survey of residents’ prescription practices may show a couple of patients who are taking three atypical antipsychotic agents simultaneously. While EBM does not support such a regimen, some patients require unusual treatments, so such a finding may not be "abnormal." Now, if the prescription survey showed a majority of patients on this regimen, then the clinical epidemiological research data may suggest that this should not be appropriate. The proposal here is that if you teach residents guidelines based on epidemiological data arising from populations, the educational outcome should be sought across patients treated by an individual resident.
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Clinical Judgment: The Advanced Resident
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The practice of psychopharmacology on the individual patient level requires clinical judgment to take into account the uniqueness of each case. This most advanced skill may prove difficult to define, quantify, and empirically study. Historically, clinical judgment has been transmitted by modeling in an apprenticeship or mentoring arrangement (some might argue that we resort to showing students what we mean when we are otherwise inarticulate). Certainly, this makes sense with procedures, as in the "see one, do one, teach one" tradition. We submit that some components of clinical judgment may be similarly elusive of linguistic description. Much of clinical judgment is based on pattern recognition. One can recognize a face, but you can only imperfectly say why or tell someone else how to do so. It is easiest to show them the face.
What if clinical judgment is encoded like implicit memory? Implicit memories, in contrast to explicit ones, cannot be explained by a person. The existence of the memory is evidenced by an intuition or "gut feeling" on how to proceed. Thus, experienced clinicians can tell you their judgment call, but they may not be able to explain how they arrived at it. This is usually written off to "clinical experience." The hypothesis here is that one of the most sophisticated physician skills—clinical judgment; that is, the intuition that fills the gap between knowledge and practice with the individual patient—may need to be observed and then practiced for full comprehension. Language may be too crude, or in the wrong cerebral hemisphere, to transmit clinical judgment to a pupil or for the pupil to verify learning back to the teacher. Should this be true, as considerable literature now suggests (11), we should move toward other forms of tests where the students show the answer to the teacher. Objective Structured Clinical Examinations (OSCE) and other forms of simulation have been devised for this purpose in medical schools. At this level of advanced residency training, however, simulations would need to be exceedingly complex and should include multiple variables that incorporate but are not limited to EBM, including patient preference, insurance restrictions, and the like. At this level, simulations cannot match real patient scenarios, and thus some advocate real-time supervision (1), in which the teacher stands by, periodically intervening and demonstrating as the student interviews the patient. This is not a new idea, except for the elimination of the one-way mirror, allowing for moment-to-moment observation, modeling, and feedback on a repetitive and cyclical basis. The advanced resident eventually becomes a partner with the teacher as they work through complicated cases step by step.
Teaching clinical judgment is hindered by its subjective nature. This is the least standardized skill, dependent on the individualized clinical experience of each physician, come instructor. The scenarios faced by advanced residents are so complex that different attending physicians may well suggest different approaches, all of them valid. Thus, no one answer is "correct," although answers may be more or less well supported by evidence and argument. In fact, part of learning clinical judgment is recognizing the tentativeness of one’s clinical intuition and that the final arbiter is the individual patient’s outcome—the datum from which clinical experience is derived. Given this, perhaps the outcome of training should be measured by patient outcomes and not by whether the attending "agrees" with the resident. Patient outcomes might include compliance with prescriptions, changes in symptoms ratings, number of psychiatric emergency service visits, patient views of quality of life and personal health, and patient satisfaction. In some settings, such factors are already used to monitor the quality of care of attending physicians; residents should also be exposed to these. Educational research that utilizes these dependent variables will encourage training that is reality-based, patient-centered, and readily transferable to practice after residency.
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Conclusion
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Educational research in psychopharmacology, especially of an empirical nature, should be encouraged. Research questions, however, should be prudently chosen. In particular, the dependent variables or outcome measures need to be carefully considered. In testing fund of knowledge, multiple-choice questions may be quite adequate and efficient, but more novel measures may need invention when testing more sophisticated psychopharmacological skills, such as critical thinking and appraisal and clinical judgment. This editorial underscores our obligation to think widely and comprehensively about these assessment measures and about the possibility of developing a more intentional and self-reflective approach to imparting the knowledge, science, and art of psychopharmacology in the care of people with mental illnesses.
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REFERENCES
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- Zisook S, Benjamin S, Balon R, et al: Alternate methods of teaching psychopharmacology. Acad Psychiatry 2005; 29:141–154[Abstract/Free Full Text]
- Oliva PF: Developing the Curriculum. Longman, N.Y., fifth ed. 2001:345–356
- Ramos KD, Schafer S, Tracz, SM: Validation of the Fresno test of competence in evidence based medicine. BMJ 2003; 326:319–321[Abstract/Free Full Text]
- Fritsche L, Greenhalgh T, Flack-Ytter Y, et al: Do short courses in evidence based medicine improve knowledge and skills? Validation of Berlin questionnaire and before and after study of courses in evidence based medicine. BMJ 2002; 325(7376):1338–1341 [Abstract/Free Full Text]
- Norman, GR: Critical thinking and critical appraisal, Gruppen, LD and Frohna, Ariz. Clinical reasoning, Norman, GR, Van der Vleuten, Newble, DI (Eds.) International Handbook of Research in Medical Education, Kluwer Acad Pub, Dordrecht, The Netherlands, 2002
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- Hatala R, Guyatt G: Evaluating the teaching of evidence-based medicine. JAMA 2002; 288:1110–1112[Free Full Text]
- Osser D, Patterson RD, Levitt JJ: Guidelines, algorithms, and evidence-based psychopharmacology training for psychiatric residents. Acad Psychiatry 2005; 29:180–186[Abstract/Free Full Text]
- Salzman C: The limited role of expert guidelines in teaching psychopharmacology. Acad Psychiatry 2005; 29:176–179[Abstract/Free Full Text]
- Oakley-Browne MA: EBM in practice: psychiatry. Med J Aust 2001; 174:403–404 [Medline]
- Gruppen LD, Frohna AZ: Ariz. Clinical reasoning. Norman, GR, Van der Vleuten, Newble, DI (Eds.) International Handbook of Research in Medical Education, Kluwer Acad Pub, Dordrecht, The Netherlands, 2002
This article has been cited by other articles:
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I. D. Glick, C. Salzman, B. M. Cohen, D. F. Klein, C. Moutier, H. A. Nasrallah, D. Ongur, P. Wang, and S. Zisook
Improving the Pedagogy Associated With the Teaching of Psychopharmacology
Acad Psychiatry,
June 1, 2007;
31(3):
211 - 217.
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INTRODUCTION
Fund of Knowledge, The...
