Abstract
This is a most timely article on this important topic given the fact that several university medical curricula are currently under review and teaching practices are in a significant state of flux.
The authors freely admit the limitations of their survey, and that the central question of ‘quality’ as opposed to ‘quantity’ is not answered in their article.
They also state that the survey ‘raises more questions than it can answer’ and they hope discussion will be stimulated on undergraduate teaching in psychiatry. From my reading, they have certainly achieved that goal.
Several thoughts immediately present themselves. Why are teaching curricula (subject focus and quantity) so disparate? What factors determine inclusion and weighting of topics in undergraduate psychiatry teaching? What is the overall philosophy and aim of teaching of psychiatry at undergraduate level? How does such teaching accommodate itself to changing systems, needs, community and professional expectations? The authors have not attempted to answer these questions but have highlighted through their survey that such issues should be considered and addressed.
In looking at the central question of quality versus quantity, the following issues become apparent. Quality of undergraduate psychiatric teaching should consider:
1. Aims and philosophical objectives of the teaching program upon which the fabric of didactic and clinical experience are built.
2. Comprehensive curricula taking into account current student needs (including examinations), future professional requirements and community expectations need to be developed. Topic areas and weighting with ongoing evaluation and review (i.e. a ‘dynamic’ curriculum) should influence course teaching practices.
3. Method of teaching and materials. In this area, as is evident in the paper, considerable variation exists. There is always a need for a sound, comprehensive and up-to-date knowledge base. It is hard to see how this can be achieved in universities that provide little lecture or tutorial input. Currently available undergraduate textbooks seem not able to fulfil all of the requirements expected in providing such core knowledge. Computer-assisted learning with a focus on problem-solving techniques is still currently under development and not universally available.
4. Clinical experience and supervision/tuition. It would appear from this paper that clinical placements are the mainstay of undergraduate psychiatric teaching; yet, as the authors point out, evaluation of the adequacy of this teaching is difficult. The teaching site and hence availability of clinical cases must be considered so that exposure to a wide variety of problems can occur. The debate over public and private psychiatry and the thorn of labelling some psychiatric problems as more serious than others spills over into the undergraduate teaching area. In some universities (the minority rather than the majority) rotations to private psychiatric hospitals, community clinics and general practitioners (GPs) help overcome this situation. From my own experience in teaching GPs at postgraduate level, their needs are for more information and experience in dealing with mood and anxiety disorders, personality disorders, somatoform disorders and basic psychotherapeutic techniques. These areas are found wanting in undergraduate tuition and confirmed yet again in this survey. It is quite amazing that some universities still have no formal program in old age psychiatry, and who teaches the rudiments of intellectual disability psychiatry in the de-institutionalised era?
Other issues that should be considered for quality teaching are: qualifications and experience of teachers (e.g. academics vs clinicians, use of registrars, etc.); evaluation of student's attitudes, biases and perception of psychiatry (both before and after psychiatric experiences); coordination in teaching and clinical exposure with other medical disciplines (e.g. shared case conferences, symposia, etc.); opportunity for students to discuss personal or ‘group’ problems throughout the course and receive appropriate support from professionals, mentors or peers; and a system of regular monitoring, evaluation and revision with feedback to teachers, clinicians, curriculum committees and administrators.
Psychiatry can be bewildering and threatening to the medical student as it is to many lay people. Negative and stereotyped attitudes combined with feelings of inadequacy and scepticism are not uncommonly encountered in surveys of students undertaking psychiatric placements. New language and skills not obviously related to clinical expertise gained in other disciplines must be acquired and insights into different moral and social systems can prove daunting. Psychiatric teaching and experience should be seen by students as relevant, valuable, interesting and personally enlightening. A strong nexus with other medical disciplines must be discernible. If such occurs, ‘quality’ has probably been achieved, but this paper hints that we are a long way from achieving that goal.