Acad Psychiatry 30:23-28, February 2006
doi: 10.1176/appi.ap.30.1.23
© 2006 Academic Psychiatry
From Yoda to Sackett: The Future of Psychiatry Medical Student Education
Joshua T. Thornhill IV, M.D. and
Lowell Tong, M.D.
Received July 3, 2005; revised October 5, 2005; accepted October 7, 2005. Dr. Thornhill is affiliated with the University of South Carolina School of Medicine, Department of Neuropsychiatry and Behavioral Science, Columbia, South Carolina. Dr. Tong is affiliated with the University of California San Francisco, Department of Psychiatry, San Francisco, California. Address correspondence to Dr. Thornhill, University of South Carolina School of Medicine, Department of Neuropsychiatry and Behavioral Science, Columbia, SC; jtt35{at}gw.med.sc.edu (E-mail). Copyright © 2006 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: The authors discuss approaches to curricular goals, methods, and assessments in the education of medical students in psychiatry. METHODS: Using current educational principles and opinions on curricular reform in medical student education, an outline for a core curriculum and an individualized approach to medical student education were developed. RESULTS: A curricular outline addressing both content and organization was developed for all students as well as those specifically entering clinical psychiatry, neuroscience research, and primary care. CONCLUSIONS: In addition to a standard core curriculum there should be a tailored approach for certain subsets of students. The core curriculum should be an "ideal minimum" that recognizes the importance of evidence based medicine and is strategically planned and learner focused.
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INTRODUCTION
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As Yoda says, "Impossible to see, the future is" (1). Nevertheless, we are asked to gaze into the twenty-first century and envision the future of psychiatric education for medical students. The purpose of this article is to stimulate discussion, while keeping in mind that the future of psychiatric education is closely linked to the future of medical education in general (2, 3).
The psychiatry curriculum should be designed from the perspective of what students should learn and how they learn best, a subtle but important distinction from what we should teach (4, 5, 6). It must be built upon sound general educational principles: activating past knowledge; input of new information/skills; integration and practice; formative feedback; and assessing mastery of knowledge/skills. Our curriculum must embrace the principles of evidence-based medicine as defined by Sackett and others: "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ... integrating individual clinical expertise with the best available external clinical evidence from systematic research" (7).
In this article we focus on the curricular needs of the student and the goal of becoming excellent physicians instilled with a sense of clinical service, intellectual curiosity, scholarly interest and compassion. This will lead to what is good for our patients and society in general and will continue to shape what is good for our service-oriented profession.
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Curricular Goals and Scope
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We first need to define, then help create, the medical student of the future. What knowledge, skills, attitudes, and behaviors does this student need? How should psychiatry and psychiatrists define these parameters and assess the student’s mastery of them? We challenge the assumptions that 1) all students need an identical comprehensive curriculum, and 2) our primary duty is to transmit core knowledge and skills to them.
We would emphasize from the outset that as knowledge in our field, as in other fields of medicine, continues to expand, it becomes increasingly difficult to define what are the fundamental elements of our specialty. By suggesting a core curriculum, we do not imply that psychiatry or the problems of our patients are less important than others. We think this is the approach all specialties should take; however, we will limit our discussion to psychiatry. We simply stand by our opinion that hard decisions need to be made in all aspects of medical student education and that by sticking to the premise that more is better we lose respect in the eyes of our students for not being able to define what is important. We also lose the ability to ensure that our students have learned the information.
We propose moving to a more tailored approach to psychiatric education. Our rationale is that there is great variation among students in terms of where they come from and where they are going, and therefore they do not all need the same level of knowledge and training. To be more learner-focused in our approach to education, we place all students into one large group (the entire class) and then into subsets, three of which are of particular interest to psychiatry: the primary care bound student, the neurosciences investigator bound student, and the clinical psychiatry-bound student groups.
All Students
We believe there is a core set of fundamental knowledge and skills that all students must master, and these include some basic psychiatric knowledge and skills. Examples of these are taking a medical history (including psychiatric history) and performing the physical exam (including a mental status exam). Therefore, psychiatrists must be directly involved with the planning and teaching of this core curriculum.
We have divided the core psychiatry related knowledge and skills into five areas: 1) basic neuroscience and human emotional, interpersonal and cognitive development; 2) undifferentiated patient presentations; 3) major psychiatric diagnostic categories; 4) special psychiatry topics; and 5) unique communication skills
We have resisted the impulse to be exhaustively inclusive and detailed. In fact, we will not even list specific items for the first category, since details are likely to evolve more quickly than for the other categories.
Undifferentiated Patient Presentations
Because patients rarely arrive in neatly defined diagnostic categories, we expect students to conduct a sound clinical assessment and treatment approach for patients who arrive with these undifferentiated presentations in either psychiatric or nonpsychiatric setting:
1. The confused patient—cognitive and information processing impairment (e.g., delirium, dementia, schizophrenia);
2. The dangerous patient (e.g., suicidal, homicidal, self-mutilating, psychotic, high risk-taking);
3. The patient who feigns symptoms or a disorder;
4. The patient with family/interpersonal/school/work problems (e.g., child/adolescent with school difficulties, relationship issues);
5. The patient with a disturbed mood; and
6. The stressed or severely anxious patient (e.g., stress with physical symptoms).
Diagnostic Categories
While the treatment of certain disorders such as schizophrenia and dementia is likely to be managed by a specialist, we expect all students, regardless of eventual specialty, to understand the diagnostic criteria, evaluation and treatment of these diagnostic categories: 1) addiction, substance use, and withdrawal; 2) anxiety disorders; 3) mood disorders; 4) personality disorders; and 5) somatoform and factitious disorders.
Using the mood disorders category to illustrate levels of knowledge and skill, we would expect every student to be able to detect a mood disturbance through interviewing and using a screening tool, determine whether the disturbed mood is pathological or not, know how to refine the diagnosis, understand common treatment modalities, and be able to educate the patient about diagnosis, prognosis and treatment options.
We recognize that neither our undifferentiated patient presentation nor our diagnostic categories reflect the entire depth and breadth of psychiatry. Entire diagnostic categories, including dissociative disorders, eating disorders, sexual disorders and sleep disorders, are not included in our defined core. We emphasize that this does not reflect the significant distress that these disorders create for our patients but instead is consistent with our attempt to propose a minimum core curriculum that will hopefully encourage further self-directed learning by students in these other areas of our field.
Special Psychiatry Topics
At the level of having a framework for understanding how to identify, screen and then consult a specialist in the acute setting, every student should have basic knowledge about these areas: 1) abuse (as recipient and perpetrator); 2) capacity to make informed medical decisions; 3) confidentiality issues as they pertain to psychiatric ethics and stigma; and 4) involuntary psychiatric commitment.
Unique Communication Skills
While our expertise in these areas certainly overlaps with the expertise of our colleagues in other fields, it is important that psychiatry take an active role in developing the curriculum for these objectives. We must ensure competency in the following basic skills: 1) ability to provide patient education; 2) ability to "read" a patient; 3) ability to build rapport; 4) ability to deal with angry/agitated patients; 5) ability to deal with patients who have serious/chronic mental illness; 6) ability to discuss serious news; 7) ability to recognize and understand strongly negative or positive reactions to a patient; and 8) ability to understand process versus content.
In addition to these fundamentals, all students must be exposed to the essence of the practice of psychiatry and psychiatry as a dynamic field of medicine so that they can also understand: 1) that persistent serious disorders like schizophrenia, bipolar disorder and severe recurrent depression are at the core of psychiatric practice; 2) that diagnosis is currently based on phenomenon and function but is likely to transform into a biological marker and pathophysiology based diagnostic system; 3) that psychiatry comes with a rich history filled with many socio-cultural and theoretical factors, and complicated by stigma, misconceptions and prejudice; and 4) that psychiatry’s boundaries with related specialties and disciplines like neurology and psychology are in flux, but that ensures our increased collaboration for the good of patients.
We would like to return to our original premise that medical student education needs to be more individualized and take into account the goals and career path of the learner. In addition to a core curriculum for all students, we need to develop a relevant, helpful and tailored curriculum for three subsets of students. These could be "elective courses" at this point. But given ongoing discussions at the graduate medical education (GME) and other levels to find ways to shorten overall physician training, a standardized, required version of this tailored approach could help achieve the much discussed goal of shortening overall training duration.
Primary Care Bound Students
We propose that for students planning on entering primary care fields, additional training and evaluation are necessary. We base our proposal on the large number of patients with mental health issues they will see in their practice and the very modest amount of time their residencies devote to this area.
Though primary care residency programs have some required elements for the assessment and treatment of basic mental and behavioral problems, a tailored undergraduate medical education (UME) psychiatry curriculum would be ideal preparation for GME training and practice. This curriculum would include more detailed knowledge and skills in assessment and actual treatment of straightforward presentations of common mental disorders. Two of many possible examples are 1) Depression: the student develops detailed knowledge about mild to moderate depression as well as of antidepressant use, side effects, and an understanding of which forms of psychotherapy are effective; and 2) Substance use disorders: the student develops a working knowledge of assessment, behavioral and social interventions and resources such as using the stages of change model, 12 step programs, and effective pharmacologic treatments.
Neurosciences Investigator Bound Students
These students would benefit from early identification and mentorship because of the need for a rigorous schedule that combines the curricular elements of the all-student group with additional emphasis on neuroscience electives and research throughout the course of medical school. Schools with medical scientist training programs (MSTP) must have psychiatrists closely involved with the formal MSTP program.
Clinical Psychiatry Bound Students
The clinical psychiatry-bound students will have plenty of psychiatry specific training over the course of their careers. Therefore, we suggest broadening their knowledge and skills in other fields, since this is their last readily available opportunity. Specific areas to encourage students to study include: basic science research relevant to the brain; complementary and alternative medicine; emergency medicine; endocrinology; neuroanatomy; neurology; neuropathology; and neurosurgery.
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Curricular Methods
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Successful learning about psychiatry can be achieved in a wide variety of learning modalities and methods. Principles are presented here with some examples, rather than detailed specifics. While acknowledging that some medical schools are experimenting with very novel curricular designs, this section is based on creating a future-oriented curriculum in a traditional 2-year preclerkship plus 2-year clerkship and elective studies UME model. Given the unique nature and diversity of each school’s curriculum, we do not want to prescribe what parts of the core curriculum should be taught in the preclinical versus clinical years. Instead we will discuss curricular methods that can be used throughout the curriculum.
Three Overarching Principles
Each department of psychiatry must commit to a strong educational infrastructure to support high quality education. This must include designated, prominent leadership, trained and skilled in medical education and capable of planning, coordinating, and implementing all departmental educational activities, including UME. Whether one person or a group, this leadership must possess: content expertise, administrative expertise and outstanding rapport with students and the school. The infrastructure must include adequate resources, such as dedicated time for educational leadership, administrative staff, space, and department-wide support for faculty and resident development as teachers.
Each department must place a high priority on current and forward-looking educational methods, which includes: incorporating modern educational theory in instruction, practice and assessment; using modern instructional technology; embracing evidence based medicine (EBM) in clinical assessments and treatments; collaboration with related specialties and disciplines. Creating a culture of self-directed learning is essential as medical knowledge in all fields continues to advance and grow dramatically; a curriculum that presents principles, overviews and examples will be more successful than attempting to teach an exhaustively inclusive list of topics, disorders and treatments.
Rather than focusing on specific minimum numbers of clerkship weeks or numbers of classroom hours, each department must create a clear curricular program comprising defined learning objectives for medical students, develop an adequate learning environment, and ensure that each student has adequately mastered baseline objectives.
Preclerkship Formal Curriculum
The two most important pedagogical principles are to maximize active learning in general and student-driven learning in particular.
Whether a particular medical school’s preclerkship formal curriculum is department or system based, and semester or block based, active learning should be maximized, to promote deeper learning and to prepare students for lifelong learning. This can take many forms such as case-based learning, small group problem sets or discussions, independent learning modules (ILM), and preceptorships. (See Table 1.) Student inquiry-driven learning should be used where possible, such as problem based learning (PBL), either to augment or as the entire curriculum. Small group settings are ideal for active clinical problem solving to enhance understanding of complex principles and the development of teamwork skills and professionalism. Lectures can be used as an introduction to or overview of new concepts and when there is no alternative to learning complex or complicated concepts.
Clerkship Formal Curriculum
The apprenticeship model clerkship is one of the most dated aspects of UME. This model has the advantages of familiarity, working with real patients and real teams. However, clerkships are often in random order, based on inpatient teams that are no longer constant because of resident work hour limits; there is a focus on performance and preparing to be an intern instead of learning clinical medicine; and tend to focus only upon acute clinical presentations. As a 2003 Institute of Medicine (IOM) report summarized, "Clinical education has not kept pace with or been responsive enough to shifting patient demographics and desires, changing health system expectations, evolving practice requirements and staffing arrangements, new information, a focus on improving quality, or new technologies" (10).
There is no easy replacement for clerkships, though some schools are attempting innovative models such as learning teams with longitudinal teaching faculty who follow a cohort of general patients over many months to whichever departments and clinical settings their evolving medical problems dictate, or learning teams which remain together through a strategically planned sequence of department-based rotations. It is our responsibility to create alternatives to the traditional clerkship model. But in the meantime, we at least need to incorporate more learner-focused elements into the clerkship. (See Table 2.)
Other innovative options include: 1) clerkships that are integrated or combined with other clerkships (such as psychiatry with neurology, or psychiatry with primary care) and 2) a consistent, set order for clerkships, which allows for a curriculum that specifically draws upon previous rotations and prepares for future ones. While variations of this are being piloted or implemented at a number of medical schools, one example is to assign each clerkship to a particular spoke around a wheel. Students should be equally distributed among the spokes at the start of the year but then rotate according to how the wheel spins in one direction for subsequent blocks. Student cohorts then rotate together in the same order, with a curriculum designed to make strategic connections with preceding and succeeding clerkships.
Advanced Formal Curriculum
Advanced courses should be strategically designed to provide at least two specific elements:
1. Subinternship in psychiatry—Especially designed for the psychiatry-bound student, is a rigorous and high-stakes inpatient-based elective that will help the student prepare for internship and will count toward any school-based subinternship requirement. The focus is on primary responsibility for a cohort of patients and reporting directly to the attending, like an intern. This is in contrast to nonsubinternship electives designed to acquaint students with various elements of psychiatry.
2. Advanced clinical elective—Designed especially for the primary care-bound, an elective focused on the screening, recognition, diagnosis and treatment of psychiatric conditions in general medical settings.
Psychiatry Research Curriculum
In those departments that have research programs, clinical, basic science, or other research electives should be offered and well advertised. Department basic scientists should be active or at least well connected in the school’s MSTP or related program to attract those students who show promise of a psychiatry research career.
The Informal Curriculum and Hidden Curriculum
Psychiatry departments must commit to a broad, forward-looking presence beyond the formal curriculum, to the informal curriculum including general medical school life. All students should have early and broad exposure to the field of psychiatry, as well as to psychiatrists in the roles of specialist and general physician. Ways to accomplish this include ensuring that psychiatrists are as involved as other types of physicians in the breadth of activities like white coat ceremonies, ongoing mentoring groups, volunteer and service programs, MSTP events, and student-faculty extracurricular activities. This kind of exposure would be particularly beneficial early, during the preclerkship years. It certainly demystifies and may even help de-stigmatize people with psychiatric problems, mental disorders and treatment. It provides an early clinical paradigm for the many students who majored in a neuroscience-related field in college, and for all students who learn neuroscience and theories of psychiatry in their UME coursework. It can serve as a very practical way to learn and practice the mental status exam.
Doctoring courses are particularly well suited for paid and volunteer psychiatry faculty participation. Psychiatrists should not be limited to expert roles in interviewing and doctor-patient relations but should be active participants in all basic clinical education activities such as general medical problem case discussions and physical exam skills. Psychiatry content needs to be featured as prominently as any other clinical content in case vignettes, and real and simulated patients with psychiatric problems need to be part of the general pool of patients used in general interviewing instruction and objective structured clinical exam (OSCE) stations.
Each department must ensure that for psychiatry-bound or at least psychiatry-interested students, psychiatry interest groups and career advising programs are established and supported.
Psychiatry clerkship grades must align with the school standard. An inflated percentage of honors grades compared to the school average only deflates the perceived level of quality, rigor and value of psychiatry.
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Assessments
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Assessments drive student learning. When constructed and applied properly, they also ensure that students have learned and mastered at a particular level. Psychiatry and every other department in each medical school should have a consistent approach to assessments. They should include objective assessments of student mastery of knowledge, clinical skills and professionalism levels, judged against defined, consistent minimum standards. A psychiatry department whose faculty uniformly agrees upon and practices a minimum standard mental status exam is well on its way toward achieving this.
Traditional end-of-rotation clerkship evaluations are often extremely subjective and based on insufficient observation. Shelf exams and well written school-based final exams are objective but are limited in their ability to assess mastery of clinical skills. Therefore, more accurate or enhanced assessment tools must be incorporated, such as 360° assessments, OSCEs and learner portfolios.
Finally, assessment of the curriculum itself is essential. Like any product, the UME curriculum needs to be evaluated by its consumers: students and residency programs. Consumer satisfaction and critique should contribute to ongoing modification and improvement of each department’s and school’s UME curriculum. The Association of American Medical Colleges (AAMC) Graduate Questionnaire, school-based instructor and course evaluations, and other methods need to be developed and used systematically to guide ongoing curricular improvements.
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Conclusions
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The future is impossible to see, but psychiatry educators must help shape it. There is no better time to act on the future of UME than now, especially with related activities underway, such as the AAMC Clinical Education Task Force; the 2003 IOM Strategies for Reform in Research Training in Psychiatry Residency; and the January 2005 Macy Conference on Neuroscience, Behavioral Science, Psychiatry and Neurology. In its full meaning and intent, evidence-based medicine must be embraced. In addition to a standard core curriculum for all students, there should be a tailored approach for certain subsets of students. The standard core curriculum (the "ideal minimum") cannot be all inclusive but instead will present students with an overview, principles, and examples and equip students with the tools and culture for further self-directed learning. The informal and hidden curricula are as strategic as the formal curriculum. A strategically planned, learner-focused psychiatry curriculum will foster effective learning and better psychiatric knowledge and patient care and is therefore ultimately good for society and our profession.
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ACKNOWLEDGMENTS
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This study was presented at the American Psychiatric Association Summit on Medical Student Education, April 2005, Washington, DC.
This study was not supported by any grant or other funding source.
The authors thank the Department of Neuropsychiatry and Behavioral Science, University of South Carolina School of Medicine; the Department of Psychiatry, University of California San Francisco; and the American Psychiatric Association.
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ABSTRACT
INTRODUCTION
