Academic Psychiatry 29:180-186, June 2005
© 2005 Academic Psychiatry
Guidelines, Algorithms, and Evidence-Based Psychopharmacology Training for Psychiatric Residents
David N. Osser, M.D.,
Robert D. Patterson, M.D. and
James J. Levitt, M.D.
Drs. Osser and Levitt are with the Department of Psychiatry at the Brockton Veteran’s Administration Medical Center, Harvard Medical School, Brockton, Massachusetts. Dr. Patterson is with the Department of Psychiatry at the McLean Hospital, Harvard Medical School, Belmont, Massachusetts. Address correspondence to Dr. Osser, Brockton VAMC, 940 Belmont St., Brockton, MA 02301; david.osser{at}dmh.state.ma.us (E-mail). Copyright © 2005 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: The authors describe a course of instruction for psychiatry residents that attempts to provide the cognitive and informational tools necessary to make scientifically grounded decision making a routine part of clinical practice. METHODS: In weekly meetings over two academic years, the course covers the psychopharmacology of various psychiatric disorders in 32 3-hour modules. The first half of each module is a case conference, and the second is a literature review of papers related to the case. The case conference focuses on the extent to which past treatment has been consistent with evidence-supported guidelines and algorithms, and the discussants make recommendations that take the relevant scientific evidence into consideration. The second half of each module focuses on two papers: 1) a published guideline, algorithm, or review article and 2) a research study. RESULTS: Residents absorb a comprehensive overview of recommended clinical practices and acquire skills in assessing knowledge that affects decision making. Satisfaction with the course is rated highly. CONCLUSION: The course appears useful by its face validity, but research comparing the attitudes and practice outcomes of graduates of this course compared with recipients of other training methods is needed.
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INTRODUCTION
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There is growing concern about how to enable physicians to use research findings in the care of their patients. Evidence-based medicine (EBM) is a way physicians can merge research with patient care (1–3). There seems to be a large gap between evidence-supported practice and typical practice (4). To narrow this gap, many practice guidelines, algorithms, and compilations of expert interpretation of evidence-based medicine have been issued in recent years. However, studies have shown that simple dissemination of these documents is generally not effective in changing practice (5, 6). Some systems designed to change behavior show promise. Examples of such systems include: computerized reminders, flowcharts posted on walls, and performance feedback and reviews. The changes in physician prescribing behavior have been modest, however (7–9). The targeted practices often return to preintervention levels, unless multifaceted, resource-intensive interventions are sustained (10).
This article describes a course in psychopharmacology for psychiatry residents designed to address these concerns and the problem of commercial influence in medical education. The authors wish to prepare students to be able to use valid new information and resist influences that are not evidence-based. Detailing, gifts, and sponsored educational products are highly influential, but, unfortunately, this influence is often in the direction of irrational prescribing, especially with respect to cost-effectiveness (11–13). Industry-sponsored education has been dominating residency and postgraduate training in recent years and is a concern throughout medicine (14).
The practice of EBM involves stepping back from a clinical scenario and asking questions about the scientific evidence that pertains to that situation (1). This is a rigorous approach to clinical decision making that may be unacceptably time consuming. For the psychopharmacologist, a four-step approach is required. The first step would be to make a criteria-based Diagnostic and Statistical Manual of Mental Disorders (DSM)–IV diagnostic impression, identifying subtypes and comorbidity. This is required because virtually all the evidence in the literature regarding psychopharmacological treatment involves the treatment of patients who have been identified by these criteria. Regardless of the validity of DSM criteria, their utility in the context of EBM is difficult to dispute (15). Next, a review of past treatment trials, including their adequacy and outcomes, must be completed. Then, the clinician must search for, find, read, and analyze, and apply the research evidence that pertains to the treatment situation (1). Finally, a treatment decision is made after the evidence information is integrated with the clinician’s knowledge of the total patient, taking into account issues such as side effect sensitivities, patient preferences, family input, and ethnic and cultural considerations (16, 17).
This process is arduous and requires use of some cognitive disciplines that may be unfamiliar to the physician. These barriers have limited the usefulness of EBM in the day-to-day practice of medicine and psychiatry. In an effort to address this problem, high- quality, evidence-based practice guidelines and algorithms have been developed by appropriately qualified entities. The physician can consult these academic products and more quickly determine what the evidence supports for the clinical scenario at hand. However, these products will usually not address all situations, and the EBM physician must still be able to utilize the four-step process to look up particular questions or determine whether there has been important new evidence since the guideline/algorithm was published.
However, as noted, physicians often do not consult evidence-based guidelines and algorithms, much less follow them. They present many reasons for not doing so (18). The most common reasons involve lack of awareness that the guidelines exist or apply (19), belief that the recommendations will not produce a good outcome; and lack of experiences with some recommended treatments and consequent discomfort with trying them. Additionally, some physicians may not trust the guidelines/algorithms, especially if they have reason to doubt whether they were rigorously and thoughtfully constructed. Many of these products come embedded in industry sponsored educational material and contain obviously biased recommendations. Even the term "evidence-based" is losing meaning and credibility these days because of its ubiquitous presence in the titles of promotional offerings. Guidelines and algorithms may also be rejected as "cookbook medicine," even though, curiously, physicians are likely to agree with the specific recommendations in a guideline when they are presented separately from that guideline (18). Finally, some physicians assert that they do not agree with the concept of EBM in general, pointing out that much of the evidence of EBM is flawed and incomplete and thus irrelevant (20).
What is the alternative? Instead of employing EBM-informed reasoning, it is well-known that physicians often fall back on faulty processes of decision making (21–23). For example, "reflexive decisions" are impulsive judgments made without consciously considering any alternative. "Bias-driven clinical judgments" occur when the physician is overconfident and thinks that he or she knows exactly what to do based on some bias. The "availability heuristic" is the tendency to grab the first answer that comes to mind and to stick with it despite evidence to the contrary.
Use of these faulty approaches is sometimes justified by referring to them as part of the "art" of medicine. Belief in this art appears to be rooted in the apprentice/mentor training model [eminence-based medicine (24)] and the model of placing special value on recollected clinical experience without adequately taking into account the unreliability of memories. The problem with clinical experience is that people tend to overestimate the frequency of intermittent reinforcers (25) (e.g., a gratifying positive outcome from a particular treatment). The validity of clinical experience is also limited by the small Ns of the previous experience, sample differences (i.e., the patient to be treated now is not really similar to the recollected previous patients), and investigator bias (i.e., the physician has an undue faith in the proposed treatment). At times, the art appears to be little more than treatment of symptoms without precise diagnosis and with unscientific, improvisational treatment selection. Dr. Abraham Flexner observed the same phenomena in his study of American medical practice almost 100 years ago. He urged reforms in medical education to produce a "scientific physician." Such a physician:
...studies the actual situation with keener attention; he is freer of prejudiced prepossession; he is more conscious of liability to error. Whatever the patient may have to endure from a baffling disease, he is not further handicapped by reckless medication... (26)
Psychiatrists are committed to the principle that each patient’s treatment should be uniquely crafted, in recognition of the uniqueness of each person. However, this principle may be misapplied, causing the psychiatrist to see treatment decision making as a process without significant evidence-based guideposts that should be considered. Though some of the resistance to EBM appears to come from a fear that it attacks the humanistic perspective of psychiatry, EBM should complement it.
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Teaching the Science and Art of Psychopharmacology
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It has been proposed that the best way to overcome these barriers is to begin training in EBM as early as possible (27, 28). This article describes a new structure for a course of classroom teaching of clinical psychopharmacology for residents at the Harvard South Shore Psychiatry Residency Training Program. It emphasizes the development of skills in practicing EBM. However, it goes beyond traditional EBM and encourages the use of rigorously constructed practice guidelines and algorithms as primary resources contributing to clinical decision making. Evidence-based guidelines and algorithms are also used as a way of organizing knowledge in psychopharmacology for the trainee (and the expert). Guidelines and algorithms provide contexts in which to place new information and compare it with previous knowledge. Using this knowledge of EBM and the contents of guidelines and algorithms, students make better decisions, and they develop the ability to identify clinical practice decisions that seem to deviate from the evidence. The course encourages them to become active consumers of many kinds of evidence (27); become skillful at detecting the biases in publications, in lectures, and in the practice of other clinicians; and learn to recognize the shortcomings of eminence-based medicine. Finally, at a time when medication costs have substantially increased, residents are encouraged to focus on evidence that pertains to making cost-effective psychopharmacology decisions (29).
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The Core Psychopharmacology Conference: a Two-Year Course
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The Core Psychopharmacology Conference (CPC) is a 2-year program for PGY-II and III psychiatry residents that meets weekly for 1.5 hours. Each year, before the CPC begins, there is a 10-week introductory didactic lecture series in basic principles of psychopharmacology, combined with structured reading of a basic text. Topics covered in the introductory course include diagnosis, neurobiological factors in mental illness, pharmacology of the medications, kinetics, neurotransmitter issues, side effect management, and risk management strategies.
The CPC utilizes clinical case conferences coupled with practice guidelines or algorithms and research studies relevant to the cases presented, including clinical studies or papers elucidating the neurobiology of the patient’s primary disorder or the mechanism of action of the medications used to treat that disorder. The CPC is organized into modules (Table 1). The first module each year focuses on basic principles of EBM and how to critically assess a paper (30, 31). Eleven psychiatric disorders are covered in the remaining 15 modules. (See Appendix 1 for specific topics.) There are a total of 64 papers read and critiqued by the resident group. Each trainee presents at least two case conferences and leads four paper discussions over 2 years.
Citations for all papers studied in the modules from 1999–2004 are available at www.mhc.com/Algorithms. Syllabus papers are chosen by the faculty and distributed at the beginning of the course each year. Resident-selected papers are chosen in relationship to a question raised by the clinical material in the case conference: the resident (with faculty supervision) researches the question, and a relevant paper is selected for review in the meeting the following week.
Some comment is necessary about the way syllabus papers are selected. The first-year syllabus contains practice guidelines, algorithms, or review article papers, depending upon what is available for each diagnosis. Algorithms are a subset of practice guidelines that are more specific and give step-by-step elaboration of issues such as treatment sequencing, dosing, and progress assessment (32). The selections in the first year syllabus draw somewhat heavily on work by the course directors (one-third to one-half are theirs), but the course directors attempt to be rigorous in critiquing their own work during the class discussions. Algorithms can be evaluated according to several parameters (33). They should:
1) Contain a critical appraisal of the quality of supporting evidence for each recommendation, and an indication of different levels of confidence in the recommendations;
2) Be thoroughly reviewed by other experts;
3) Be free of commercial bias;
4) Consider evidence of safety as well as efficacy in determining the hierarchy of decisions;
6) Offer multiple options at each step as appropriate;
7) Cover a wide range of clinical scenarios;
8) Make special effort to explain the evidence supporting recommendations that are different from what other prominent experts have concluded in their interpretation of the literature; and
9) Be kept up-to-date. It is an advantage (34) that the algorithms and decision-support information of the Harvard South Shore Program are computerized, web-based, and frequently updated so residents can always access the most recent version.
The clinical research papers in the second-year syllabus are selected for their illustrative value on matters of contemporary clinical interest and for their usefulness to the residents in gaining experience in applying the principles of critical appraisal of papers outlined in the first module. They are not intended to comprise only the best papers. Rather, they ensure coverage of a range of problems with sampling demographics, sample size, effect size in comparison with placebo, type I or II error, and statistical analytic issues. Considerable time is spent addressing the issue of placebo effect in clinical trials, and, in general, how placebo effect confounds the interpretation of personal clinical experience in psychopharmacology practice (35). Sometimes papers are chosen that provide evidence challenging common, but questionable, practices. Other papers are selected because, although not high quality, they may be among the only studies available that pertain to important decision areas. Residents are also asked to critique the algorithm and guidelines papers according to the parameters described earlier (33). The neuroscience papers are selected by one of the course directors (JJL), who has expertise in psychiatric neuroimaging.
It should be noted that this course is not the complete curriculum in psychopharmacology at this residency program. In addition to patient-based learning through supervision in various settings, there are other courses that cover research design, epidemiology, diagnosis, biological psychiatry, integrative treatment, and a didactic lecture series in psychopharmacology. Grand rounds also cover topics in psychopharmacology.
A more complete description of the operational details of the core psychopharmacology conference may also be found at www.mhc.com/Algorithms.
Although increasing numbers of medical schools and residency programs are instituting courses on the principles and practice of EBM, there have been a limited number of studies of clinical outcomes of patients treated by clinicians who have adhered to evidence-based psychopharmacology guidelines or algorithms (10, 36, 37). The course directors do not encourage trainees to follow any guidelines and algorithms in a rigid way, but rather to use the structure of the algorithms for organizing or scaffolding their evidence knowledge base so that it can be readily accessed and consulted when making a clinical decision.
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Course Evaluation
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A survey of resident opinion about the first CPC course (1999–2001) was conducted in 2001. A questionnaire was anonymously completed by all 20 of the trainees who attended the conference, and the answers were collated. Almost all respondents indicated that the course was successful in structuring their psychopharmacological knowledge and increasing their confidence in their clinical decision making. They also approved of the emphasis placed on EBM, practice guidelines, and algorithms, and reported that they frequently considered the algorithms in their clinical decisions. Several graduates commented that having learned to practice this way, and they cannot understand how others around them do not.
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Concluding Comments
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Teaching methods and their impact on professional competence should not be immune from the standards that EBM educators apply to clinical treatments. In fact, there have been calls for high quality randomized trials of different methods of medical teaching (38, 39). However, there appears to be no satisfactory method of measuring the clinical performance and competence of physicians, despite numerous efforts (40). Even if there were satisfactory methods, random assignment of trainees to different training approaches would certainly be impractical. Observational studies could be done, but these would have to try to control for the many confounding covariates inherent in the baseline characteristics of the trainees and for the quality and type of teaching that occurs in other parts of the residency curriculum. Studies should also address whether trainees continue over the long term to use the thinking processes taught in this course or whether they eventually fall back upon the automatic thinking encouraged by industry-influenced education (39). Given the lack of such studies, the authors can only present this course description for its face validity, while acknowledging that the present approach should not be assumed to be efficacious. However, we are presently conducting a study to measure residents’ attitudes toward EBM, guidelines, and algorithms 1 to 3 years after completion of the course. These results will be compared with the attitudes of graduates of a different psychiatry residency program in our area (41).
There is one published comprehensive model curriculum for psychopharmacology training. The American Society of Clinical Psychopharmacology (ASCP) has a 700-page volume, first published in 1997, (with a third edition published in 2004) which provides lecture outlines, reproductions of slides, and other information useful for organizing training (42). Earlier editions were discussed and reviewed (43–46). One reviewer stated that it lacked what psychiatric residents need the most: algorithms (43). One must add that residents need not just any algorithms, but rigorously evidence-based and unbiased algorithms (33). Indeed, the ASCP’s important curriculum does discuss a wide variety of evidence, but it does not teach how to assess and validate evidence for clinical application, nor does it structure the evidence into formal algorithms or guidelines. Even the authors acknowledge that the curriculum does not provide the critical thinking skills necessary for good clinical practice (47). The teaching approach described here complements and should ideally be combined with presentation of the knowledge base in curricula such as that of the ASCP. We are pleased to report that a description of this course, a citation of its web site, and the flowcharts of three algorithms reviewed in the course are included in the 2004 edition of the ASCP Model Curriculum.
In summary, the Core Psychopharmacology Conference establishes that EBM and high-quality, up-to-date psychopharmacology practice guidelines and algorithms should be routinely considered in daily clinical practice. The approach emphasizes case-centered learning, in which cases are directly associated with guidelines/algorithms and the evidence that supports them. Residents have an opportunity to absorb the knowledge that experts have filtered from the research literature and incorporated into the guidelines and algorithms. They learn how to use EBM techniques to find, filter, critically evaluate, and apply evidence and update their knowledge structures, including the knowledge summarized in the guidelines and algorithms. They also explore the cognitive, social, economic, and other factors that influence clinicians’ acquisition and utilization of scientific research findings in their practice.
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ACKNOWLEDGMENTS
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The authors thank Daniel Ioanitescu, M.D. for many useful discussions and for organizing the course evaluation.
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ABSTRACT
INTRODUCTION
