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Teaching Evidence-Based Psychiatry to Residents and Fellows: Developing the Curriculum

Received July 8, 2008; accepted July 9, 2008. Dr. Coverdale is affiliated with the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine in Houston; Dr. Roberts is affiliated with the Department of Psychiatry and Behavioral Medicine at Medical College of Wisconsin; Dr. Louie is affiliated with Psychiatry Residency Training at San Mateo County Mental Health Services and with the Department of Psychiatry at the University of California, San Francisco. Address correspondence to John H. Coverdale, M.D., Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, One Baylor Plaza BCM 350, Houston, TX 77030; jhc{at}bcm.tmc.edu (e-mail).

INTRODUCTION

TOP INTRODUCTION Conclusions REFERENCES

 

"Data! Data! Data!" he cried impatiently. "I cannot make bricks without clay."—Sir Arthur Conan Doyle (1)

Evidence-based psychiatry is a scholarly, disciplined, and systematic field founded on the science of epidemiology. The process begins with questions that arise from clinical situations and proceeds to retrieving the best evidence and to critically appraising and applying that evidence. The ultimate aim of the field is twofold. First, evidence-based psychiatry seeks to enhance the care of individual patients by supporting solid, data-driven decision making. Second, this field endeavors to advance clinical psychiatry by ensuring that care practices are sound, thus increasing the benefits of and facilitating the best use of what are, by definition, scarce health care resources (2). These fundamental processes constitute a cornerstone of professionalism by enabling patients and society to trust physicians intellectually (3–5) and are essential to psychiatric training (6–9).

Despite the critical importance of teaching evidence-based psychiatry to residents and fellows, Academic Psychiatry has published relatively few articles on the topic. This edition begins to rectify this deficit by featuring several articles that enhance our understanding of the practical issues and scientific basis of teaching evidence-based medicine to psychiatrists-in-training. Four articles published here (10–13) present a rationale for instructing residents about evidence-based psychiatry (10), describe individual training programs (11–12), and review the literature on how best to teach (13). The articles (10–13) also address the training of general adult psychiatry residents.

Our goal for this editorial is to briefly discuss two key themes that arise from this collection of articles on teaching evidence-based psychiatry. The first theme concerns elements and guiding principles of curriculum design, and the second concerns how to shape the hidden curriculum so as to promote the practice of evidence-based psychiatry. Our intent is to integrate some of the important processes and findings described in each of the articles and to add comments on educational training processes relevant to teaching evidence-based psychiatry.

Curriculum Design
The planning phases of curriculum design begin with an outline of the level and types of needs of residents, which, in turn, are understood in relation to the needs of patients and their communities. Planning phases include specifying curriculum and instructional goals and objectives, selecting the strategies for teaching, and selecting the evaluation techniques.

One comprehensive model for curriculum design is that of Oliva (14); this delineates step-by-step processes from the initial planning phases to evaluation. An important feature of Oliva’s model is how evaluation feeds back to the curriculum and instructional goals, allowing for ongoing curriculum revision and improvement.

The descriptions of the individual training programs published in this issue (11, 12) exemplify some of the key components of curriculum design, from the specification of goals and objectives to methods of evaluation. There are some remarkable features of these curricula. For one, they all encouraged active learning styles. Mascola (11) used learning theory to guide the choice of teaching strategies and to develop skills and self-mastery. The Motivational Interviewing Model was adapted for a preliminary discussion about changing clinical practice to more completely comply with evidence-based psychiatry, and the information presented to trainees was tailored to their knowledge. Emphasis was also given on how social-learning theories guided role-modeling skills and facilitated self-mastery (11).

There are, in fact, few controlled trials to guide the design of curricula for psychiatry trainees when teaching evidence-based psychiatry. The only one identified by Agrawal (13) concerned the teaching of critical appraisal skills in a journal club setting (15), which is an important but limited aspect of evidence-based psychiatry. In this context of few trials, the choice of teaching strategies should be heavily informed by learning theory.

Each of the model programs also illustrated several guiding principles of curriculum design. According to Oliva (14), these principles include scope, relevance, balance, integration, sequence, continuity, articulation, and transferability (Table 1). Mascola (11) and Feinstein et al. (12) emphasized the importance of integrating the curriculum with routine clinical practice. Sequence, and the related dimensions of continuity and articulation, was illustrated by Feinstein et al. (12) in a description of the curriculum over 3 years of a residency program. In this latter case the term progressive was used to describe the curriculum whereas perhaps Oliva would suggest that the more apt term was articulation (Table 1).

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TABLE 1. Oliva’s Guiding Principles for Improving the Curriculum

Finally, the individual training programs demonstrated a willingness to revise the curriculum according to feedback and formal evaluation. In one case (12), an examination was developed and validated based on earlier work on assessing competency in evidence-based medicine (16). The authors have kindly made this examination and the scoring instruments available to readers. Such a resource should be useful to curriculum designers, especially given Agrawal’s (13) call to adopt available instruments for use in psychiatric educational settings. We emphasize the importance of incorporating clinical outcomes in the outcome measures used to evaluate the teaching of evidence-based psychiatry.

The Hidden Curriculum
One of Agrawal’s (13) key recommendations is that instruction in evidence-based psychiatry should be aligned with the hidden curriculum. The hidden curriculum broadly refers to the cultural premises, unspoken expectations, and unwritten codes of conduct that can influence clinical practice and training (16–18). The hidden curriculum can undermine teaching when it conflicts with the practice of evidence-based psychiatry. This can occur, for example, when questioning more senior team members is discouraged on the premise that hierarchy is necessary (17). References to the literature may be routinely accepted as authoritative without critical appraisal of the validity and importance of that literature (19). In other circumstances, there may be the pretense or appearance of certainty about evidence that is unclear or incomplete. Conflict may also occur when data legitimately leads to clinical equipoise. That is, conflict may occur when the choices are not obviously guided by data outcomes, at which time values and reasoned arguments assume greater importance in clinical decision-making (2).

Many senior faculty members were not taught evidence-based medicine during medical school or residency. Both the specific and the more general philosophical underpinnings of evidence-based medicine may seem foreign to faculty members who have not obtained continuing medical education in evidence-based medicine. Without a shift both in attitudes and skills of faculty members regarding the use of informational resources in the daily practice of medicine (as espoused by evidence-based medicine), the hidden curriculum passed on by these faculty members is likely to subvert the teaching of evidence-based psychiatry.

Such a shift, we opine, likely will have a major influence on the practice of medicine and on public health. No matter the strength of the argument for evidence-based medicine and the role it should play in medicine, it now has the zeitgeist behind it. Clinicians may more readily accede if the information revolution is viewed as inevitable in medicine. The new paradigm for medicine is coming, if it has not already arrived, with electronic medical records, a personal computer on every physician’s desk, and internet searches for patient queries.

Data on the "success" and complication rates of individual, named physicians in the care of specific conditions (e.g., surgeons) are now published routinely on the internet in the United States and throughout the world. Indeed, patients are encouraged to use these data in identifying preferred caregivers. Even "skeptics" will develop new respect for data and will want to understand more about how they are generated and interpreted. This "transparency" of physician data will alter the system of care for patients in organized systems and will transform clinical practice in a short time.

The number of psychiatrists changing to evidence-based psychiatry in daily practice might be explored by self-report, or by tracking literature searches performed by psychiatrists, or by compiling data on the frequency with which systematic reviews are accessed. Further success of an evidence-based psychiatry curriculum, beyond lip service to the same, may require a shift in the hidden curriculum—but the difficulty of this should not be misjudged.

Agrawal (13) argued that the hidden curriculum can be aligned with evidence-based psychiatry by creating a tightly integrated educational culture and by shifting the hidden curriculum toward one that fosters evidence-based practices. Two methods to achieve this included faculty development and educational prescriptions. Agrawal (13) described how educational interventions were extended to faculty as a distinctive feature of the individual training programs. These interventions were illustrated by developing a four-member faculty group who would teach themselves the requisite knowledge and skills so as to encourage learning for residents (12). A process of negotiation of treatment decisions by trainees and attending psychiatrists also counters hierarchical decision-making processes and enhances trainees’ autonomy (11).

Journal clubs and grand rounds can directly influence the hidden curriculum should faculty and other disciplines be included. Agrawal (13) suggested that journal clubs might become more effective when they faithfully model the processes of evidence-based psychiatry. One challenge in an environment of evidence-based medicine is to show how journal clubs are integral to patient care and not abstract exercises unrelated to the real constraints of time, logistics, and technology faced by many busy clinicians (20). The same can be said of grand rounds; it was speculated that those who simply instruct or transfer facts may not necessarily bring about useful changes in clinical behavior (21). The alternative is to shape grand rounds to follow evidence-based psychiatry formats, beginning with an individual case scenario and involving active audience participation (21).

The hidden curriculum can also be influenced by setting educational prescriptions and critically appraised topics (22), with all team members included or given access to the final product. An education prescription specifies the patient problem, who is responsible for answering it, and by when, and it reminds everyone of the steps of searching, critical appraisal, and relating the answer back to the patient (21). Team members could obtain evidence quickly with an evidence cart (23) containing multiple sources of information, such as critically appraised topics, MEDLINE, and the Cochrane Library. Both patients and the clinical team benefit when skills in accessing and applying evidence become more efficient and effective (21).

One innovative educational project involving faculty warrants mention here; this program teaches research literacy and evidence-based psychiatry directly to training directors. A National Institute of Mental Health funded grant was awarded to Michele Pato and her educational consultants, including Lisa Mellman and Deborah Cowley (personal communication, Luke Manley, current project manager, May, 2008). In the three annual preconferences for training directors held to date in this project, topics taught included question asking, searching, and the critical appraisal of randomized controlled trials, diagnostic tests, and systematic reviews. Methods of teaching have included small and large groups and lectures. One of the explicit goals of this project is to encourage program directors or others to teach on the same topics and to develop the curriculum; we look forward to learning more about its progress.

Conclusions

TOP INTRODUCTION Conclusions REFERENCES

 
Taken together, the collection of articles published here (10–13) represents a rich resource for curriculum design for training psychiatrists with a heightened focus on evidence-based medicine. These articles emphasize the importance of process in training residents and fellows to practice according to the standards of evidence-based psychiatry. Students should also be engaged in thinking about what to do when evidence does not exist or is incomplete, uncertain, or carries clinical equipoise as part of this effort. Given the relative absence of data from clinical trials, curriculum design should be guided by theories of learning and by wisdom derived from experience in education. Ideally, any components of the hidden curriculum that undermine teaching will first be identified and then shaped to align with the formal curriculum. To this end all faculty should be trained to model the practices of evidence-based psychiatry.

We hope to continue to publish reports that describe the processes of developing the curriculum. In particular we seek information on planning, including local needs analyses, goals, and specific behavioral objectives. We also seek information on the principles of learning utilized in the curriculum, fidelity to the educational interventions, and outcomes. Such details on the processes of planning and implementation are unavailable in many earlier reports (20). It is important to identify the educational needs of faculty, including voluntary faculty, who assume important roles and responsibilities in teaching. We need information on how evidence-based psychiatry is taught across programs, what specific topics are taught, methods of assessment, and individual program barriers to teaching. As far as we are aware, no such survey has yet been published.

We must develop our knowledge of efficacious teaching processes by conducting rigorously designed studies, including randomized and quasi-randomized trials, multisite studies, and pretest/posttest research designs. Although high-quality randomized controlled trials are challenging to conduct in educational settings, they are no less necessary to educational research than to clinical practice (24). A commitment to best evidence medical education necessitates a commitment, in turn, to developing this knowledge base. Perhaps in the future, therefore, we can position ourselves by obtaining enough data to systematically review controlled trials on teaching evidence-based psychiatry to residents and fellows. In the meantime, of course, we should lean heavily on research pertaining to the teaching of evidence-based medicine to medical students and to residents and faculty belonging to other specialties.

We welcome manuscripts that help to achieve these goals. Developing the curriculum to promote evidence-based practices, when informed by well-conducted educational research, should contribute to the integrity of the profession of psychiatry. We sincerely thank the authors for contributing to our knowledge on how to teach evidence-based psychiatry to residents and fellows.

ACKNOWLEDGMENTS

 
The editors wish to thank Ms. Ann Tennier for her assistance in preparing this editorial. Ms. Tennier and Dr. Roberts are funded through the Research for a Healthier Tomorrow-Program Development Fund, a component of the Advancing a Healthier Wisconsin endowment at the Medical College of Wisconsin.

REFERENCES

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