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Where There’s Smoke, Can There be Fire?

Received December 7, 2007; accepted December 12, 2007. Dr. Kramer is affiliated with the Department of Psychiatry and Behavioral Medicine at Wake Forest University Health Sciences in Winston-Salem, N.C. Address correspondence to Stephen I. Kramer, M.D., Wake Forest University Health Sciences, Psychiatry, Medical Center Blvd, Winston-Salem, NC 27157-1087; skramer{at}wfubmc.edu (e-mail).

This issue of Academic Psychiatry includes a report on a model curriculum designed to improve resident education on promoting smoking cessation in the mentally ill (1). The journal has devoted considerable space to the various elements of curriculum development and implementation, but very rarely do we see a complete and integrated product. The smoking cessation curriculum is practical, clinically relevant, based on educational need, empirically tested across several sites, and meets survey-derived teaching parameters of psychiatry residency educators. There is even a suggestion of a positive clinical outcome. But will it be used? I fear it may not be.

The authors from this research team began with a real clinical problem, the overrepresentation of a defined health hazard, nicotine use, in psychiatric patients. They designed their curriculum from the bottom up, rather than by the usual approach in pedagogy, from the top down. Bottom-up design ensures that the structure and content of the curriculum has a strong probability of meeting the specific objectives and intended outcome. Top-down design places more weight on expert-level philosophical and intentional factors, although the final product may miss its mark by a considerable distance.

Prochaska et al. (2) surveyed psychiatric residents regarding their knowledge and sense of competence in treating, and interest in improving their efforts in reducing, nicotine dependence in their patients. Others have surveyed general and child and adolescent psychiatry training directors regarding training in addictions and the hurdles in applying any relevant curriculum, such as limited clinical training sites and availability of appropriate faculty (3, 4). This journal has also addressed the ethics and proper construction and reporting of survey results from educational research (5, 6), and an excellent manual is widely available (7).

In our previous research on model curricula (8), Lawson Wulsin and I compiled examples of readily available model curricula, demonstrated an evaluation system, and proposed a dissemination method. To summarize our recommendations, we asked: Can the curriculum be implemented? Does it address a defined topic area? Are there specific objectives? What are the required resources and core references to carry out the curriculum? What are the evaluation methods? Prochaska et al. (1) answer all of our recommendations admirably.

The venue and methods of instruction described in this new report are applicable to a wide variety of programs, although the authors only involved selected California general psychiatry residency programs. The authors considered this field testing of the curriculum to be multi-site but independently executed. The educational design was consistent with a multiphase, multimodal group process format that reinforces adult learning models. It was also consistent with the mentor-protégé developmental phases on reinforcing the importance of specific skills (9, 10). The design can be applied in a psychotherapeutic frame, where expert faculty, but not necessarily residents, view tobacco dependence as an issue for exploration (11), or in continuity clinics that allow for the reinforcement and encouragement for patient behavioral change—a venue favored by residents, though threatened as a training entity (12). Web-based materials could provide educational resources for residents, and the potential for continuing medical education following training is evident (13). Even the costs of the curriculum are considered, but likely underestimated. A model for such estimations used at one particular site was published in Academic Psychiatry, but the considerable value of voluntary faculty and donated services and materials were not included in the formula (14).

Evaluation methods, generally the weakest part of model curriculum development, are well addressed by Prochaska et al. (1). Both educational and clinical assessments received considerable design weight, and there were a number of similarities with the popular psychotherapy course by Beitman and Yue (15). This curriculum relies in part on self-assessment and is amenable to 360-degree methods and patient surveys, the favored modes of evaluation by residents studied in at least one training site (16).

Despite this research team’s previous survey of training directors (17), in which over 90% had moderate to high interest in a tobacco cessation curriculum and were willing to provide a 4-hour course, with 85% willing to make it required, why do I share the pessimism of others (18) regarding the application of model curricula? I believe there are three important factors. First, course coordinators and residency training directors desire to have some autonomy and a personal hand in curriculum development used at their own sites. Tinkering, modifying, and adjusting an externally developed product may not be sufficiently satisfying, even though the usual cry of "Let’s not reinvent the wheel" is heard all too often in departmental education committees. Second, there may be legitimate program-specific features that lead educators to believe "it will not work here," accompanied by an unwillingness to make the adjustments necessary for a new curricular module to fit in. Finally, promotion committees at academic centers are placing more emphasis on the clinician-educator career track with evidence of excellence based on the dissemination of new knowledge subjected to peer review. Applying someone else’s model curriculum may weigh less in the eyes of promotion committee members than creating one’s own materials.

In the case of this model curriculum on reducing nicotine dependence in psychiatric patients, I hope I am wrong. The authors provide an empirically tested turn-key product built on evidence-based clinical and educational practice and tailored to the needs of trainees and program directors. This curriculum should be disseminated widely and used avidly.

REFERENCES

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15. Beitman BD, Yue D: Learning Psychotherapy: A Time-Efficient Research-Based and Outcome-Measured Psychotherapy Training Program, 2nd ed. New York, WW Norton, 2004
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