Academic Psychiatry 29:167-175, June 2005
© 2005 Academic Psychiatry
Teaching Psychopharmacology: Two Trainees’ Perspectives
Anna M. Georgiopoulos, M.D. and
Jeff C. Huffman, M.D.
Drs. Georgiopoulos and Huffman are with the Department of Psychiatry at the Massachusetts General Hospital, Boston, Massachusetts. Address correspondence to Dr. Huffman, MGH 55 Fruit St., Warren 1220C, Boston, MA 02114 ; jhuffman{at}partners.org (E-mail). Copyright © 2005 Academic Psychiatry.
|
ABSTRACT
|
OBJECTIVE: To describe our experience of learning clinical psychopharmacology during residency, in order to assist educators planning psychopharmacology curricula.METHODS: We describe how psychopharmacology teaching was structured in our program, dividing our experience into two phases, early residency (PGY-I and PGY-II) and late residency (PGY-III and PGY-IV). We discuss the advantages and disadvantages of various teaching strategies, and make recommendations for improvement. RESULTS: Our educational needs differed substantially in early and late phases of training. We identified areas deserving additional focus, including dealing with special populations, practical treatment dilemmas, systems issues, and ethics. Learning to manage both patient-psychopharmacologist and mentor-trainee relationships was crucial to our growth as psychopharmacologists.CONCLUSIONS: A developmental approach that takes into account residents' skill levels and prior experiences is important in implementing psychopharmacology didactics, patient assignments, and supervision. We recommend presenting principles of clinical psychopharmacology in practical, appropriately contextualized formats, and with gradually increasing complexity.
|
INTRODUCTION
|
As two residents graduating from a psychiatry residency program that has a tradition of strong psychopharmacology training, we have been asked to describe our experience of learning clinical psychopharmacology during residency. As we have progressed through residency, we have been impressed with the many difficulties inherent in teaching and learning psychopharmacology. It is important to balance practical, case-based learning with a comprehensive didactic curriculum that provides a suitable base of knowledge. At the same time, residents need to understand broader issues that may impact our practice, such as the role of pharmaceutical organizations and their influence. Although there has been an explosion of psychopharmacology research and clinical knowledge in recent years, the time and attention of psychiatric residents and faculty are subject to multiple competing demands.
Given these challenges, a number of authors have proposed models for the development and evaluation of educational curricula in clinical psychopharmacology (1–3). In these studies, satisfaction with clinical psychopharmacology teaching has been high (2, 3). Similarly, we have been generally very pleased with this aspect of our residency education, but we also have suggestions for further refinement. We believe that training is most effective when it is targeted to the appropriate developmental level (i.e., when the knowledge base and experience of residents are considered). In addition, we found our psychopharmacology teaching most beneficial when it was focused on practical issues and included specific doses, durations of treatment, common difficulties, and case-based examples.
We have divided this article into two sections: early residency, encompassing PGY-I and PGY-II training, and late residency, focusing on PGY-III and PGY-IV. We found that our educational needs differed substantially in these two phases of training. In this article, we will describe the structure of the educational program in psychopharmacology that was in place during each stage of our residency. We will describe what was most effective, indicate aspects of the curriculum that could benefit from improvement, and highlight topics that felt underrepresented in our education. It is our hope that this discussion of our training experience will be useful to educators in other programs.
|
Early Training: PGY-I and PGY-II
|
In this section, we will describe our experience learning psychopharmacology during the first 2 years of residency. We will explain how the early years of training were structured during our residency and the various modes of psychopharmacology teaching that were used during this time. We will then outline the portions of this training that were most and least useful. Finally, we will discuss our recommendations for further improvement.
Structure
In the Massachusetts General Hospital (MGH)/McLean psychiatry residency program, accepted residents have several options for their PGY-I year. They may select a combined medicine/neurology/psychiatry year, or may spend their entire internship in internal medicine or pediatrics. As a result, the PGY-I psychiatry experience of residents in our class ranged from 0–4 months, in highly variable settings. Psychopharmacology teaching for residents who chose psychiatry rotations in their first year largely consisted of service-specific "on the job training" with close supervision.
More systematic psychopharmacology didactics began in the PGY-II year, and consisted of the following:
1. Orientation
In July of PGY-II, rotation-specific orientations (four hours per week) covered key psychopharmacology topics, particularly in emergency psychiatry and the management of agitation. The Residents’ Handbook, a 200-page, pocket-sized volume written by senior residents, was also distributed. This handbook includes sections with practical psychopharmacology information, such as common dosing regimens, schedules for laboratory monitoring of medications, and common and serious side effects for the major classes of psychotropic medications.
2. Chief Residents’ Lecture Series
In August of PGY-II, we attended 16 hours of lectures given by faculty and PGY-IV residents as a crash course in the things that are most important to beginning psychiatrists. These lectures were organized by chief residents, and included the most anxiety-provoking topics for residents. Approximately 8–10 hours were devoted to psychopharmacology, with topics such as "the practical treatment of anxiety disorders" and "emergency psychopharmacology."
3. PGY-II Didactics
Throughout residency, the program provided one afternoon per week as protected didactics time. In the PGY-II year, this included 1–2 hours weekly devoted to a series of lectures in biological psychiatry and psychopharmacology.
4. Outpatient Clinic
In the PGY-II year, one afternoon per week was set aside for the development of a small outpatient clinic practice. This practice included the gradual accumulation of 8–12 patients for medication management. In addition to this practical experience, the resident had 30 minutes of individual psychopharmacology supervision from a staff member during each clinic afternoon.
5. Inpatient and Emergency Rotations
Residents in the PGY-II year spent the majority of their time on rotations on inpatient psychiatric units or in the psychiatric emergency department. Each of these rotations provided both patient-specific teaching about issues regarding psychotropic medications and additional formal didactics appropriate to the rotation. Designated attending psychiatrists were accessible 24 hours per day for questions that arose while evaluating patients.
6. Journal Club
Once per month, PGY-II residents presented articles at a residency-wide meeting, critiquing research methods and findings with the help of a faculty discussant.
What Was Effective
We found both the orientation didactics in July and the chief residents’ lecture series in August to be extremely effective. Topics in these series included the basics that residents need to know to function as a junior psychiatrist, such as how to select and dose antidepressants and how to start and monitor treatment with mood stabilizers. Interactive case-based teaching on the management of agitation when on call incorporated discussion of chemical restraint strategies and intramuscular (IM) medication dosing. Other lectures covered the "worst case scenarios" that new residents most fear, such as detection and management of neuroleptic malignant syndrome. By identifying the topics that residents were most likely to face early in their residency and by (correctly) assuming a very limited knowledge base about psychopharmacology, these lectures helped to reduce anxiety and to provide important facts to the novice resident. The Residents’ Handbook was highly valued for similar reasons, serving as a transitional object and portable reference that addressed the most common and most critical issues in psychopharmacology.
Lectures in biological psychiatry and psychopharmacology during the remainder of the PGY-II year were usually quite beneficial. Experienced psychopharmacologists and researchers presented important information about fundamental topics in psychiatry. Occasional discussion of pertinent cases helped to solidify the material. When these lectures were appropriately targeted to beginning residents, they were immensely useful and provided a framework for future learning.
Weekly individual supervision with an attending psychopharmacologist was a wonderful opportunity to learn outpatient psychopharmacology, and also to address issues arising on inpatient or emergency room rotations with a trusted supervisor in a relaxed setting. The availability of senior psychopharmacologists who donated their time to supervise novice residents was remarkable, and we were exceedingly pleased with the supervision we received.
In addition, we greatly appreciated the 24-hour availability of backup supervision. Many of our emergent supervision questions focused on issues of medication selection, dosing, or side effects. Such supervision is crucial for beginning residents, both for the safety of patients and to ensure the ability of residents to learn from difficult situations they encounter. Having mechanisms in place for junior residents to reach their seniors, attendings, and administrators whenever needed supported a culture that trainees are not alone and should always err on the side of asking for help.
During inpatient and emergency room rotations in PGY-II, formal psychopharmacology didactics were a valuable supplement to on-the-job supervision. Exposure to information in a clinically relevant context helped us as beginning residents to cement learning. For example, it was useful to cover use of depot medications while rotating on the bipolar and psychotic disorders unit. Similarly, lectures on evidence-based psychopharmacology, neuropsychiatry, and psychopharmacology in medically ill patients given by attending staff on the medical-psychiatry unit helped immensely in caring for the patients we encountered there.
What Was Less Ineffective
Some psychopharmacology didactics during PGY-II were difficult for junior residents to absorb. For residents new to psychiatry, we found that it was important to have simple questions answered before proceeding to more detailed issues. Occasionally it became clear that a lecture had been originally prepared for an audience of researchers or psychiatrists seeking continuing medical education; these lectures were not developmentally appropriate for psychiatrists in early training. In addition, some lectures focused on specific subtopics—often the lecturer’s special interest or a current controversy in the field—while missing broader, more fundamental points. As junior residents trying to get a handle on basic issues, we found excessive lecture time or large amounts of assigned reading devoted to esoteric topics discouraging.
Furthermore, we found that lectures or handouts consisting of long lists of treatment options or problems (such as side effects of lithium, management of sexual side effects of selective serotonin reuptake inhibitors (SSRIs), or augmentation strategies for treatment-resistant mood disorders) can be daunting for residents if adequate guidance is not provided. New residents need to know what is clinically significant, what strategy to consider first, and how to go about it.
Teaching was often excellent in areas where established treatment guidelines had been developed; treatment algorithms generated by expert panels for primary care physicians or psychiatrists were useful to us as beginning residents in systematizing our practice. However, there was a paucity of didactic instruction regarding areas in psychopharmacology where such guidelines have not yet been established, such as the use of psychotropics for patients with borderline personality disorder. Teaching the art of psychopharmacology in areas where the evidence-based literature is poor can be challenging. However, not addressing such issues can leave new residents perceiving a seemingly unbridgeable gap between the practice they see in the course of apprenticeship and what they learn in formal teaching. Effective lecturers used several strategies to overcome this problem. They used interactive case-based teaching liberally and drew residents’ attention to the basis for their suggestions, noting which were based on reports in the literature, which on local custom, and which on personal clinical experience.
What We Wish We Learned
During the formative stages of training, we felt that residents needed more formal teaching about practical issues, such as how to start, stop, and dose medications safely. Other key issues include clinically relevant drug-drug interactions, interactions with alcohol or street drugs, and situations in which generic and brand name drugs may differ. Relying on patient-specific apprenticeship on inpatient units or patient-specific supervision in the outpatient clinic can potentially leave residents with important knowledge gaps or idiosyncrasies in their approach to common problems. In addition, we would have benefited from more discussion of how to present medication options to patients and talk to them about side effects, particularly in the outpatient setting.
Some psychopharmacology supervisors are expert at helping residents learn to detect and handle dynamic issues arising in the course of short psychopharmacology visits. For example, we found that taking medications meant very different things to different patients; having experienced supervisors who understood these issues helped us to manage patients’ feelings and behavior as well as our own in a responsible and therapeutic manner. More of this kind of teaching, which helps residents learn to integrate psychotherapy techniques into their practice of psychopharmacology, would have been valuable.
We would have appreciated further guidance about how to build the crucial skills required for independent study of psychiatry and psychopharmacology. More advice about what educational material to read and when to read it would have been greatly beneficial. Lecturers giving multiple journal articles as handouts sent a message that the reading of copious journal articles was appropriate. However, we found that handbooks summarizing important issues may be all that is needed (and feasible) for extra reading in PGY-II. We also found that we needed help learning to interpret information from pharmaceutical companies.
Structured training in practice management issues was lacking early in residency and would have been useful. As simple as it may sound, it can be challenging for beginning residents to learn how to create effective patient lists, how to select appropriate coverage for outpatients when away for vacations or extended absence, how to decide what actions to take while providing such coverage for other psychiatrists’ patients, and how to develop personal policies regarding cancellations and no-shows. In addition, it can be difficult to navigate through managed care systems, as with obtaining prior authorizations for nonformulary medications. Beginning residents also struggle with medicolegal and ethical issues, including good documentation, limits of confidentiality, and informed consent in psychiatrically ill patients. Other issues for more systematic teaching could include:
1. When and how do you need to contact a patient who is not coming in for care?
2. How can you respond to patients who request specific medications that may not be appropriate for them?
3. When is it necessary to limit patients’ supply of medications or refills?
4. In what situations can or should you tell a patient that you can no longer continue to work with them, and how do you do it well?
5. How do you decide how to handle the issue of pager accessibility with patients, in light of multiple personal and professional needs?
|
Late Training: PGY-III and PGY-IV
|
In this section, we will describe the structure of our psychopharmacology education during late residency. As in the prior section, we will discuss the most and least useful aspects of our psychopharmacology training in this phase of residency and make suggestions for improvement.
Structure
The majority of our psychopharmacology training in PGY-III and PGY-IV occurred in the context of increased outpatient work. Our experience treating patients and receiving supervision in outpatient clinics was supplemented by education during required PGY-III rotations. In addition, we continued to attend one afternoon per week of didactic lectures targeted to our year of training.
1. PGY-III and PGY-IV Didactics
Weekly didactics continued throughout residency. At least 1 hour per week was devoted to biological psychiatry and specialized topics in psychopharmacology such as natural remedies and the use of medications during pregnancy.
2. Outpatient Psychopharmacology Modules
Longitudinal psychopharmacology education in PGY-III consisted of modules lasting 1–2 months, each covering a specific class of illness or population: depression, bipolar disorder, substance abuse, geriatrics, psychosis, anxiety, perinatal and reproductive psychiatry, and obsessive-compulsive disorder. Each module was run by clinical researchers experienced in the appropriate field, with members of their research and clinical teams providing lectures and supervision. Residents were assigned to each module in groups of 4 or 5, attending a weekly lecture and biweekly group supervision together. Evaluations of new patients with presenting problems appropriate to the current module were scheduled for each resident every 2 weeks. Half of these evaluations were directly observed by a psychopharmacologist teaching in the module who could provide immediate feedback. The remainder were performed independently by the resident, and later discussed at module-specific group supervision. As residents followed these and other cases over time, they used their individually assigned psychopharmacology supervisor for guidance. Finally, monthly clinical case conferences brought residents together with a senior faculty member for detailed presentation, interview, and discussion of a difficult outpatient case of the residents’ choice.
3. Time-limited PGY-III Rotations
In addition to this outpatient psychiatric experience, PGY-III residents had four half-time rotations spread over the course of the year: consultation psychiatry (4 months), community psychiatry (4 months), the psychopharmacology consultation service (2 months), and an elective (2 months). The consultation psychiatry rotation in PGY-III enhanced residents’ knowledge about psychopharmacology in medically ill and geriatric patients, reinforcing important information about drug-drug interactions and comorbid conditions. The service facilitated this learning with thrice-weekly didactic rounds led by the chief of the consultation service, in addition to individual supervision for each inpatient consultation case seen by the resident. Community psychiatry rotations exposed PGY-III residents to special populations, to varied settings such as patients’ homes, nursing homes, or schools, and to the range of community supports available to keep chronically ill patients out of the hospital. The psychopharmacology consultation service at McLean Hospital was established to provide expert consultation for psychiatric inpatients with complex psychopharmacological issues; residents on the service saw patients individually and discussed each case at rounds with an experienced psychopharmacologist. Popular electives included opportunities to work with specialized populations, including psychiatric inpatients with neurological problems or developmental disabilities.
4. Child and Adolescent Psychiatry
In addition, PGY-III residents gained experience in pediatric psychopharmacology through biweekly evaluations of new child and adolescent outpatients under supervision, with opportunities for ongoing treatment. While formal didactics on pediatric psychopharmacology were limited, discussion of the use of psychotropic medications in children frequently arose in supervision with child psychiatrists.
5. PGY-IV Elective Activities
PGY-IV residents may learn advanced psychopharmacology and supervisory skills in the context of specialized senior rotations or chiefships. For example, one of us (A.G.), who was Psychopharmacology Chief Resident at MGH, supervised trainees on difficult issues with outpatients and managed medications for pregnant and postpartum women as part of the MGH Perinatal and Reproductive Psychiatry Program, receiving supervision from clinical researchers in the field. As Consultation Psychiatry Chief Resident, J.H. taught psychopharmacology to PGY-II residents during the August lecture series and to PGY-III residents and followed patients at the Harvard Bipolar Research Program while receiving supervision from attending staff in that program.
What Was Effective
The psychopharmacology modules were highly valued for their practical focus and the opportunity to learn from faculty experts. Attendings who specialized in psychopharmacology gave excellent lectures in their areas of expertise, and provided informative case-based supervision in an informal, small group format. Exposure to patients with a variety of problems allowed us to refine our diagnostic and therapeutic skills for many different disorders (e.g., series of questions that can be used to diagnose unusual forms of obsessive compulsive disorder (OCD), how to inquire about psychosis in a compassionate yet effective manner, and the usual dosing of lithium in the elderly). Perhaps the most valuable experiences of all were the directly observed evaluations, in which we received immediate feedback on interview style, diagnosis, and treatment planning from an expert in the type of patient being evaluated.
Working with varied patient populations in diverse settings in PGY-III allowed residents to employ a wide variety of psychopharmacologic options. We could learn to use depot medications in a community psychosis clinic, monoamine oxidase inhibitors (MAOIs) on the psychopharmacology consultation service, and intravenous haloperidol on the medical consultation service. Such different settings also helped us learn to do the kind of assessment and treatment that is appropriate for a given patient at a given time. For example, on the psychopharmacology consultation service and for their outpatient case conferences, we had the opportunity to do an in-depth evaluation of patients, including an extensive review of treatment history and psychosocial issues. The inpatient consultation service provided a place to practice doing as much or as little intervention as was requested and needed.
Supervision was a crucial, and most often superb, component of our psychopharmacology education. Many individual psychopharmacology supervisors were noted to be enthusiastic and gifted teachers. The availability of supervisors for consultation on urgent issues between scheduled supervision times via pager or e-mail was highly valued by residents. We especially appreciated the opportunity to have supervisors meet and interview our outpatients when a treatment difficulty arose. Group supervisions also allowed an opportunity to hear about other residents’ cases, thereby expanding our range of experience.
We found that numerous opportunities for excellent mentorship in areas related to psychopharmacology were available. Most supervisors were enthusiastic when approached about advice regarding an academic career in psychopharmacology or a resident’s interest in joining a clinical psychopharmacology research program. Supervisors often facilitated the creation of academic projects from clinical scenarios that arose in the course of psychopharmacology supervision; these projects helped us think more critically about patient issues while developing academic skills. Residents who elected to participate in larger ongoing clinical research studies developed their understanding of important questions in clinical psychopharmacology research and practice. Residents with this kind of experience may well have become more savvy about reading the psychiatric literature, learning how to assess research methods and the quality of published studies. They may also have become more systematic in their own clinical psychopharmacology practice, incorporating research scales or mood charts adapted from clinical trials.
What Was Ineffective
On rare occasions, the match between a psychopharmacology supervisor and resident was a poor fit. Residents, fearing a negative evaluation from their supervisor or retribution for "telling on" the supervisor, sometimes felt reluctant to reveal the extent of their discomfort. There were limited structured mechanisms for residents to provide performance feedback to supervisors and facilitate discussion of difficulties. Although it would have been possible to arrange for a change in supervisors when appropriate, there was no formal mechanism to request such a change.
Although supervisors were usually available to residents when needed, advanced residents also found that close supervision could be difficult to obtain in some settings, particularly during elective activities. This was especially bothersome in clinics with patients who had severe illness or who required specialized psychopharmacological knowledge. As we gained experience and confidence during the course of residency, we learned to work more efficiently and independently. However, despite this apparent competence, even senior residents do not thrive in clinics with undue service demands and limited supervision. Although senior residents are able to take advantage of increasing flexibility in their practices, they still require structure and guidance to avoid feeling overwhelmed and to ensure optimal patient care.
Finally, while we were generally quite satisfied with the didactics in biological psychiatry and psychopharmacology, we found that a number of the lectures at the end of our residency repeated information from lectures we had previously attended. Good program-wide coordination of didactics becomes increasingly important as residents advance, to be sure that material is not too basic or repetitive and that residents are not left with major gaps as they graduate.
What We Wish We Learned
As with our early residency experience, we would have appreciated more systematic and formalized discussion about "practice management" and difficult situations. For example, it can be challenging to decide when to provide both medications and psychotherapy for a patient and when and how to "split" the treatment with other mental health colleagues. More information about the legal and clinical aspects of collaboration when psychiatric treatment is split—such as how to share responsibility and organize communication between colleagues—would have helped us to systematically develop our own practices in these areas. Learning more about strategically employing ancillary services would also have enhanced our practice of psychopharmacology; we would have appreciated information about how to judiciously use social services, pharmaceutical company indigent care programs, and psychoeducational brochures and web sites to enhance treatment availability, compliance, and patient satisfaction. Finally, more explicit discussion of when to get consultation—from other psychiatrists on a difficult case or from treaters in other specialties (e.g., neurology or medicine)—would have helped us to develop criteria for such decisions and reinforced that it is okay to ask for help with a tough case.
A greater focus on "special populations" would also have helped us to feel more prepared for the variety of issues that practice is likely to bring. Discussions of the use of psychopharmacology in geriatric patients, in pregnant patients, and in children were touched upon in lectures but not routinely covered in supervision. Similarly, residents require specific teaching to understand how culture can influence the presentation of psychiatric disorders and how the belief systems of both patient and physician can influence treatment. For example, residents may misinterpret clinical events such as severe side effects or poor response to medications if they are not familiar with the differential metabolism of psychotropic agents in cultural groups more likely to have mutations affecting cytochrome p450 oxidative enzymes.
As senior residents, we would have appreciated more attention to helping us learn to manage our patient caseload in a way that fit our personal style. By the end of training it is important for residents to know when to push ourselves to take on more challenging cases and, conversely, when to recognize warning signs that we are trying to do too much and need to set limits to protect ourselves. Certain supervisors encouraged us to try out pharmacology visits that were shorter and longer, more and less frequent, and combined with therapy or separate; even greater encouragement to test our boundaries and increase our flexibility would have enhanced our growth as clinicians.
Additionally, as we became more comfortable with our knowledge of psychopharmacology, we would have benefited from a greater focus on our development as teachers. Although we often acted as informal teachers and mentors to medical students during our training, we received little preparation or guidance about how to teach someone else to manage psychotropic medications. More emphasis on our changing role from learners to teachers of psychopharmacology during late residency would have prepared us more fully for work as clinical team leaders, researchers, and administrators after graduation.
The mentorship we received about developing a career in clinical psychopharmacology research was excellent. However, we would have appreciated greater guidance about how to integrate clinical psychopharmacology into other kinds of practice. We found that mentors were frequently tempted to recommend career paths similar to their own, and at times supervisors found it difficult to provide advice about managing patients on psychotropic medications in other practice settings. Particularly when academic psychopharmacology mentors may not be engaged in exactly the kind of career that residents plan to pursue, the resident may need suggestions about finding other mentors with similar interests.
Finally, during training we were exposed to a number of residency-sponsored roundtables and debates regarding potential positive and negative influences of pharmaceutical companies on psychiatric education, research, and practice. It was beneficial to participate in frank discussions with faculty members who have been involved in pharmaceutical company-sponsored speakers’ bureaus and research, as well as with those who have chosen not to do so. We would have appreciated even greater exposure to the many aspects of this complex topic. Many residents find it a relief to have clear limits in place regarding their interactions with pharmaceutical representatives. However, as restrictions on such contact with trainees increase, residents may not develop a clear sense of how they wish to handle these issues following graduation from training, creating a potential area of vulnerability. Ongoing open exchange and structured discussions with faculty on these topics could help residents to better formulate a personal policy about interacting with pharmaceutical companies and accessing them as sources of information and research funding as our careers continue.
|
Conclusion
|
In conclusion, we have been very pleased with our experience of learning clinical psychopharmacology during residency. We have had the opportunity to care for a sufficient number of patients in a variety of settings without, in most cases, feeling overburdened by our caseload. We have attended excellent lectures on a variety of pertinent topics, and our supervisors have been both informative and available. Our program does not explicitly follow the model psychopharmacology curriculum as formulated by Glick et al. (1). However, many of the principles laid out in this model curriculum are incorporated in the course of our training. These include case-based learning; a didactic program that includes a "crash course" at the beginning of training and more advanced work in later years; case conferences that integrate psychopharmacological and psychotherapeutic approaches to patients; journal club with exposure to the research literature; strong individual and group supervision; and exposure to subspecialized psychopharmacology units. The vast majority of lecture topics suggested by Glick et al. (1) have been covered in our psychopharmacology training, although we have highlighted above areas about which we would have liked even more information. We do believe that our program could benefit from further refinement, and that the refinements that we suggest may be beneficial to psychiatry residents in other programs, as well.
First and foremost, a practical approach to the fundamental principles of discussing, prescribing, and maintaining patients on psychiatric medications seems to us to be the key to effective teaching of psychopharmacology. Presenting information in a relevant setting clarifies the connection between what residents are learning and the treatment of their patients. Contextualizing instruction in this way engages residents’ interest and enhances their ability to ask good questions, retain material and apply what they have learned to real situations. The importance of the simplest details of psychopharmacology practice—how to explain medications to patients, how to dose common medications, and what to watch out for in the days and weeks after starting medications—cannot be overestimated, and should play a large role in teaching during early residency. Although advanced residents are able to handle more complex diagnostic and treatment issues, the emphasis in their education should still remain largely practical.
As we have emphasized, it is crucial for faculty to consider the developmental level of the resident when planning didactics, patient assignments, and supervision. In order to meet residents’ needs at each stage of training, lectures must be well coordinated throughout the curriculum. Didactics should systematically emphasize key information in an increasingly complex manner while avoiding undue repetition. Early clinical experiences should be relatively basic and closely supervised, while later experiences should challenge more senior residents and provide greater independence.
Even for senior residents, however, clinical work in psychopharmacology should remain primarily an educational activity. While autonomy and experiential learning are valuable, the availability of ongoing close supervision—especially in seriously ill populations—reduces anxiety and enhances learning. In addition, it is tremendously important to help residents understand how to navigate systems of care, use ancillary services, and develop optimal practices. This may include basic principles such as arranging vacation coverage and handling treatment noncompliance, as well as more complicated issues such as managing collaborative treatments and ethical dilemmas. Focusing on such issues in the course of psychopharmacology education highlights the need for psychiatrists to identify factors that will give their patients the best possible chance of benefiting from the medications they prescribe.
Finally, as with most things psychiatric, communication is a key component of psychopharmacology education, allowing residents to develop good clinical skills in psychopharmacology without feeling alone or overwhelmed. Having effective systems in place for residents to evaluate lectures and other formalized learning will help curriculum directors to modify their educational program as needed. In addition, a mechanism for regular, systematic feedback between supervisors and residents provides an opportunity for both to bring up difficult issues and discuss their perspectives on the supervisory experience. Psychopharmacology teachers who are readily available, flexible, and carefully discuss nuts-and-bolts issues in a manner attentive to residents’ stage of training have the opportunity to promote resilience and foster professional growth in the next generation of clinicians, researchers, and teachers.
The generalizability of our experiences and recommendations is reduced by the limited scope of our experience. First, we are only two out of 16 members of our residency class. Other members of our class may have had different experiences, different needs, and different recommendations about improvements in our psychopharmacology curriculum. Also, we are both interested in careers in academic psychiatry, and therefore may have overvalued training experiences that prepared us for academic careers while undervaluing portions of the curriculum that were important for residents interested in other types of psychiatry careers. Finally, we have been fortunate enough to train at a large academic institution with a vast array of available supervisors, multiple research programs to explore, and significant financial resources. Other programs may have different resources and different overall teaching goals.
Despite these limitations, we feel that many of our primary recommendations would apply to most residency training programs. A psychopharmacology curriculum that emphasizes practical issues, focuses on matching didactic material to the educational level of the resident, considers larger systems of medical care, and keeps an ongoing focus on communication and feedback about the curriculum would seem to serve nearly any training program well. Such curricula would give each program the best chance to produce psychiatrists who are knowledgeable, confident, and effective in their use of medications to help patients with mental illness.
|
REFERENCES
|
- Glick ID, Janowsky DS, Salzman C, et al: A proposal for a model psychopharmacology curriculum for psychiatric residents. Neuropsychopharmacology 1993; 8:1–5[Medline]
- Lathers CM, Smith CM: Development of innovative teaching materials: clinical pharmacology problem-solving (CPPS) units: comparison with patient-oriented problem-solving units and problem-based learning—a 10-year review. J Clin Pharmacol 2002; 42:477–491[Abstract]
- Naranjo CA, Shulman RW, Ozdemir V: Development and evaluation of a clinical psychopharmacology educational curriculum. J Clin Pharmacol 1997; 37:474–479[Abstract]
This article has been cited by other articles:
|
|
|
|
 
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.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Lazarus
The Role of the Pharmaceutical Industry in Medical Education in Psychiatry
Acad Psychiatry,
February 1, 2006;
30(1):
40 - 44.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. D. Jibson
Psychopharmacology Training in Psychiatric Education: The Debate
Acad Psychiatry,
June 1, 2005;
29(2):
120 - 123.
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. F. Klein
Comments on Psychiatric Education
Acad Psychiatry,
June 1, 2005;
29(2):
128 - 133.
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2005
Academic Psychiatry.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
