Objectives For The Undergraduate Teaching Of Psychiatry -

Research papers

Objectives for the undergraduate teaching of psychiatry: survey of doctors and students D Goerg,1 C de Saussure2 & J GuimoÂn3

Objectives The principal aim was to assess the psychiatric topics that doctors and students considered most important for undergraduate teaching. Differences between doctors and students, men and women, physicians/students with or without an interest in psychiatry were examined. Design A mailed questionnaire was used concerning the knowledge and skills of psychological/psychiatric medicine considered to be needed in medical practice. Setting The Medical School of the University of Geneva. Subjects Doctors and undergraduate medical students in their last 2 years of medical training. Results Both doctors and students agreed on most topics, even though the students tended to give all items a higher rating. Both groups agreed on the importance of the following main topics: the doctor±patient relationship, identi®cation and management of the principal psychiatric disorders and their associated risks and problems of a psychosocial nature. Those doctors

Introduction Faced with the changes currently taking place in western medicine, the appropriateness of undergraduate medical teaching is being brought into question. A number of factors are exerting an in¯uence on medical practice: scienti®c and technological discoveries, the restructuring of health-care and social security systems, the changes in the medical clientele brought about by demographic factors ± such as ageing for example ± and economic factors, such as the spread of unemployment

1

Sociologist, Sociological Investigation Unit, Psychiatry Clinic 1, University Hospitals of Geneva, 2MD, Rampe de la Treille 3, Geneva, Switzerland, and 3Professor and Chairman of the Department of Psychiatry, University Hospitals of Geneva, Geneva, Switzerland Correspondence: D Goerg, DeÂpartement de psychiatrie, 2, Chemin du Petit-Bel-Air, CH-1225 CheÃne-Bourg, Geneva, Switzerland

showing an interest in psychiatry tended to accentuate the importance attached to interpersonal skills. The male and female doctors and students expressed very similar opinions. The female doctors, however, tended to attach greater importance to relational±emotional aspects and to disorders affecting children and adolescents than did their male colleagues, which is probably a re¯ection of the speci®c role that women still play within our society. When asked to assess the current teaching they received in medical school, the students considered that certain important aspects of psychiatry were insuf®ciently taught. Conclusion These results con®rm the importance of teaching psychiatry with an emphasis on problems encountered in general practice. Keywords Attitude of health personnel; education, medical, undergraduate, methods; psychiatry, *education; questionnaires; Switzerland; teaching, *methods. Medical Education 1999;33:639±647

and poverty which has an in¯uence on disease. In some medical schools, traditional teaching is being replaced by problem-based methods resulting in a need for a re-examination of course syllabuses and the methods needed to teach them. The teaching of psychiatry, like that of other medical disciplines, must face up to these changes. This teaching must satisfy two complementary educational requirements: ®rst, it has to provide basic psychiatric knowledge for medical students in general and secondly, it has to provide a sound psychiatric background for those students who will be specializing in psychiatry. Numerous authors have stressed the necessity of teaching directed towards medical practice and have set out the objectives of psychiatric training for all medical students1±3, while others have put forward more speci®c models4. Students were interviewed concerning their psychiatric training and their attitudes towards psychiatry5. A

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few researchers questioned the doctors themselves to try to determine which aspects of psychiatry are essential in medical practice. Lists of topics taught to medical students were submitted to various categories of doctors: general practitioners, psychiatrists, doctors responsible for training, residents, hospital doctors, doctors in private practice6±9. The results underlined the importance of the knowledge required to manage the principal psychiatric disorders and to develop interpersonal skills. Although such knowledge is considered important by doctors, its teaching continued to present a problem10. Failings in teaching methods can result in a lack of treatment for patients with a high level of psychiatric morbidity or the inappropriate prescription of antidepressants and tranquillizers. The Medical School of the University of Geneva is currently introducing problem-based teaching methods. The Department of Psychiatry, which is involved in this change, decided to survey doctors and students on the psychiatric knowledge and skills needed by all doctors, in order to answer the following principal questions: · What psychiatric and psychological topics do doctors and students believe to be the most important for undergraduate teaching? · Is there agreement or disagreement between doctors and students? · For both doctors and students, are there differences between men and women? · Does the opinion of those with an interest in psychiatry differ from those who have no speci®c interest in this discipline? · According to the students, to what extent are the important topics actually taught?

Methods Populations

Two populations were surveyed, one of doctors and one of students. In 1995, a total of 1593 questionnaires were sent out to Geneva doctors in private practice and those who, in public health establishments, had also completed their specialization and thus held positions in the medical hierarchy at the level of senior resident or above. In 1996, another questionnaire was sent to 227 medical students attending the University of Geneva. They were in their last 2 years of medical training (end of ®fth and sixth-year students) which was still of the traditional type. Teaching of psychiatry then included courses in introduction to psychosocial medicine in ®rst, second

and especially third years, and a course in psychiatry in the ®fth year. This course, 4 h per week during 26 weeks, was composed of theoretical presentations and practical seminars with patients. Its primary aim was to provide students with the knowledge and skill necessary to identify, diagnose and propose treatment for the principal mental disorders. The possibility of psychiatric clerkship existed, although it was very rarely used. Questionnaires

The questionnaire sent to the doctors in 1995 consisted mainly of a list of 23 psychiatric topics generally taught to medical students. The topics are shown in Table 1 with their exact wording, but in a different order. This list has been used by Johnson and Snibbe in the United States6 and by GuimoÂn et al. in Spain7. Two new items were added (basic principles of molecular biology and neuroimaging related to psychiatry and knowledge of the normal and pathological ageing process). Doctors were asked to answer the following question: `what speci®c psychiatric information and skills should a non-psychiatric doctor have?'. Each topic had to be rated on a scale ranging from 0, `not at all important' to 3, `essential'. The questionnaire sent to the doctors also included questions concerning their ®eld of specialization and, for the non-psychiatric physicians, the speci®c training in psychiatry they had had (postgraduate psychiatric clinical training, participation in Balint or sensitivity groups). The questionnaire sent to the students in 1996 included the same list of 23 psychiatric topics, and students were also asked to answer the question about knowledge and skills necessary to a non-psychiatric physician. In addition, in order to investigate possible discrepancies between the importance accorded by students to the different psychiatric topics and the teaching they say they had received in these ®elds, the list of 23 psychiatric topics was used to evaluate the extent to which these various aspects were dealt with at medical school. Students were asked to answer the following question: `To which extent had the following topics been taught during undergraduate studies?'; each topic had to be rated on a scale ranging from 0, `not at all' to 3, `very extensively'. The questionnaire also included items concerning planned speciality and psychiatric experience (psychiatric clerkship, participation in training groups). Statistical methods

In order to compare answers concerning the topics considered important (between doctors and students,

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Table 1 Psychiatric knowledge and skills necessary to the non-psychiatric doctor according to doctors and students. Rank (in descending order for doctors) and percentages of higher ratings (value 2±3 on a scale 0±3)

What speci®c psychiatric information and skills should a non-psychiatric doctor have? The ability to talk with patients about their personal problems The ability to evaluate the risk of suicide or the need for psychiatric hospitalization An awareness of when and how to refer a patient to a psychiatrist A familiarity with the dynamics of the doctor±patient relationship A basic knowledge of alcohol and drug abuse An understanding of the emotional aspects of the chronically ill or dying patient An understanding of the physiological concomitants of emotional stress. A working knowledge of common psychopharmacologic medications A working knowledge of the social resources available to the patient The ability to differentially diagnose the principal psychiatric syndromes A working knowledge of normal and pathological ageing A basic knowledge of current psychiatric treatment modalities An awareness of psychodynamic principles in evaluating a patient's behaviour An understanding of the behaviour disorders of children and adolescents An understanding of normal personality development The ability to diagnose and treat family and marital disturbances An understanding of sexual problems and their management The ability to carry out brief psychotherapy A familiarity with the principles of behaviour modi®cation The ability to diagnose and manage the mentally retarded An understanding of the principles of psychoanalytic theory A familiarity with the major types and uses of psychological tests Basic knowledge of psychiatric aspects of molecular biology and neuroimaging

Doctors (n = 697)

Students (n = 147)

Fisher test

Rank

Rank

% value 2±3

% value 2±3

P

1 2

98á0 92á4

1 4

100á0 98á6

± **

3 4 5 6

89á9 88á6 81á8 81á0

9 3 2 6

95á2 99á3 100á0 96á6

* *** *** ***

7

77á1

10

95á2

***

8 9 10

72á6 71á7 66á5

5 7 8

96á6 95á9 95á9

*** *** ***

11 12 13

64á3 61á6 61á1

11 13 12

93á8 89á7 91á7

*** *** ***

14

56á6

14

88á4

***

15 16 17 18 19 20 21 22 23

54á9 45á5 44á2 24á1 22á3 15á9 15á3 11á9 11á9

15 17 16 19 21 18 22 20 23

87á0 80á0 80á7 60á4 55á3 68á5 43á5 57á9 25á0

*** *** *** *** *** *** *** *** ***

* P < 0á05; ** P < 0á01; *** P < 0á001.

women and men, doctors and students with or without an interest in psychiatry) and the extent to which these topics were taught to undergraduates (between female and male students), ratings were dichotomized into two categories: higher ratings (2, 3) and lower ratings (0, 1). The Fisher exact test was used to compare groups with respect to percentages in each category.

Results Principal characteristics of the sample populations

Doctors A total of 697 analysable questionnaires were returned giving a response rate of 44%. Since the characteristics of the reference population are not accurately known, it

was not possible to determine whether our sample was representative. The doctors who responded worked in various medical specialities. The doctors considered in this study as working in primary care were general practitioners, internists and paediatricians, who in the great majority worked exclusively in private practice (GPs 92%, internists 64% and paediatricians 75%). They accounted for 53% of the total. The non-primarycare physicians ± specialists such as radiologists, dermatologists, surgeons, etc. ± accounted for 26% and psychiatrists for 21%. Slightly more than a quarter (27%) of the doctors who responded were female. A higher proportion of the women were specialized in psychiatry (33% vs. 16% of the men) and fewer specialized in primary care (43% vs. 57%). The mean age of the doctors was 48 years; the women were younger

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than the men (mean age of 45 years vs. 49 years). Altogether two-thirds of the doctors worked in private practice (65%), more than a quarter worked in public health establishments (27%) and 8% worked in both the private and the public sectors, there being no difference between men and women in this respect. Almost half the male and female non-psychiatric physicians (47%) had taken part in training groups for psychological and interpersonal problems (such as Balint groups) or had received some postgraduate clinical training in psychiatry, which can be interpreted as an expression of interest in a psychiatric-type approach. Students The response rate was 65%; 147 questionnaires were returned on time. The students had a mean age of 25á6 years (22±42 years). Like most Swiss medical students they had begun, at the age of 19, very selective studies which last for 6 years; doubtless, for some of them, these studies represented a change of career path. Females accounted for half the sample population (54%). Most of the students were undergoing, or had already completed, their clerkships in different medical specialities (86%) and thus had personal experience with patients. The remaining 14% were in a special programme in which they took some of their ®nal examinations before their clerkships. Although the vast majority had already decided on a speciality, one-®fth of the students questioned (21%) had still not chosen their postgraduate training. Through clerkship in psychiatry (16%) or participation in training groups for interpersonal relations (14%), a number of the students had already acquired some psychiatric experience. If we include those students who thought they would eventually specialize in psychiatry (6%), it may be said that more than a quarter of the students who took part in this study (28%) expressed some interest in this ®eld. Psychiatric knowledge and skills required by the non-psychiatric physicians

When questioned concerning the importance of certain types of psychiatric knowledge and skills in medical practice, both doctors and students expressed clear preferences (Table 1). Doctors The 10 psychiatric topics considered to be most important (Table 1, ranks 1±10) corresponded primarily to the ability to handle the patient±doctor relationship, to detect and deal with cases of the principal psychiatric disorders and to treat illnesses which were often

prolonged and had psychosocial implications. The topics considered to be moderately important included, above all, knowledge of the normal and pathological development of patients at different stages in life and the ability to treat these different problems. Finally, the topics thought to be of least importance concerned speci®c psychiatric techniques as well as state-of-the art aspects of psychiatric research. Students Overall, there was agreement between doctors and students concerning the most important, moderately important and least important topics. The 10 most important topics were the same for both groups, although their relative order of importance was slightly different. The students attached a higher level of importance to knowledge about alcoholism and drug abuse and to pharmacology, and attached less importance than doctors to the ability to know when to refer a patient to a psychiatrist and to the concomitants of emotional stress. The students, however, gave a higher rating to all topics, and this difference between students and doctors was statistically signi®cant. Differences between male and female doctors and students

For both doctors and students, there was extensive agreement between men and women concerning the relative importance of the various topics. This was true for the purely psychiatric topics (differential diagnosis, treatment, drugs, etc.), for the doctor±patient relationship, normal development, various problems such as alcohol and drug abuse and for the social resources available to patients. There were some differences, however (Table 2). Among the doctors, the women attached greater importance to the topics concerned with emotive states and interpersonal relations and to disorders affecting children and adolescents. Among the students, the women attached more importance to a few topics concerning interpersonal relations (short-term psychotherapy), ageing and family disturbances. Subjects with an interest in psychiatry

Doctors A speci®c interest in psychiatry was measured, for the non-psychiatric physicians, on the basis of postgraduate psychiatric clinical training undergone and/or participation in training groups on interpersonal relations. Since this interest was much more pronounced among

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Table 2 Psychiatric knowledge and skills necessary to the non-psychiatric doctor according to gender among doctors and students. Percentages of higher ratings (value 2±3 on a scale 0±3): only items with statistically signi®cant differences Doctors

F (n = 187) M (n = 504) Fisher P Students

F (n = 77) M (n = 67) Fisher P

An understanding of the emotional aspects of the chronically ill or dying patient

87á6

78á4

**

A working knowledge of normal and pathological ageing

97á4

89á2

*

An understanding of the physiological concomitants of emotional stress

83á3

74á9

*

The ability to diagnose and treat family and marital disturbances

87á8

71á0

*

An awareness of psychodynamic principles in evaluating a patient's behaviour

67á6

58á7

*

The ability to carry out brief 69á7 psychotherapy

49á2

*

An understanding of the behaviour disorders of children and adolescents

62á3

54á4

*

* P < 0á05; ** P < 0á01; *** P < 0á001.

primary-care doctors (general practitioners, internists, paediatricians) than among non-primary-care physicians (58% vs. 25%), it was decided to focus on the former. Fifty-one per cent had participated in training groups and 21% had postgraduate psychiatric training. The primary-care physicians who expressed an interest in psychiatry (Table 3) stressed the importance of several topics and, in particular, those concerned with the acquisition of interpersonal techniques (brief psychotherapy and techniques for behaviour modi®cation, for example). Students More than one-quarter of the students (28%), both male and female, expressed an interest in psychiatry. However, this interest had very little in¯uence on the relative importance attached to the various different aspects of psychiatry considered. Teaching

With regard to teaching, the students rated the various items systematically lower than the importance they attached to knowledge and skills in these same ®elds, except for the topic of molecular biology and neuroimaging as related to psychiatry. Several of the ®elds which they, like the doctors, believed to be the 10 most important were considered to be little or insuf®ciently taught (Fig. 1). This was most particularly true for the social resources available to patients. It was also the

case for the knowledge of when to refer a patient to a psychiatrist, the evaluation of the risk of suicide, the special dif®culties associated with chronic patients and the patient interview. For other important ®elds, assessment of the level of teaching was more positive (alcoholism and drug abuse, psychiatric drugs). There were no signi®cant differences between the men and the women with regard to assessment of teaching except for one topic (the emotional aspects of the chronically ill or dying patient), which the women rated less favourably.

Discussion Consensus concerning the importance of various psychological and psychiatric subjects in undergraduate training

There was general agreement between the doctors and students surveyed on the psychiatric knowledge and skills required for medical practice, and which should therefore be covered in undergraduate clinical training. The following three aspects were considered to be most important: the doctor±patient relationship, detection of the principal psychiatric problems and their associated risks, problems or illness with an important psychosocial component. Although it is obviously important to know how to manage the doctor±patient relationship, the detection and management of the principal psychiatric disorders is also a very important aspect of medical practice.

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Table 3 Psychiatric knowledge and skills necessary to the non-psychiatric doctor according to the existence of an interest in psychiatry among primary-care doctors and students. Percentages of higher ratings (value 2±3 on a scale 0±3): only items with statistically signi®cant differences Interest

Interest

Yes (n = 211)

No (n = 155)

Fisher P

Students

A familiarity with the dynamics of the doctor±patient relationship

95á3

86á3

**

An understanding of the emotional aspects of the chronically ill or dying patient A working knowledge of common psychopharmacologic medications A basic knowledge of current psychiatric treatment modalities A working knowledge of normal and pathological ageing An understanding of normal personality development The ability to diagnose and treat family and marital disturbances An understanding of sexual problems and their management The ability to carry out brief psychotherapy A familiarity with the principles of behaviour modi®cation An understanding of the principles of psychoanalytic theory

87á2

76á5

**

A familiarity 64á1 with the major types and uses of psychological tests

86á3

78á4

*

77á1

64á9

**

71á1

58á4

**

66á3

51á9

**

62á0

51á3

*

57á4

47á4

*

45á0

26á6

***

35á6

19á7

***

20á0

10á3

**

Primary care doctors

Yes (n = 40)

No (n = 105)

Fisher P

42á5

*

* P < 0á05; ** P < 0á01; *** P < 0á001.

Thus, the ability to make a differential diagnosis, knowledge of psychopharmacology and the ability to identify the risk of suicide, the need for admission to a psychiatric hospital, or for referral to a psychiatrist, are considered an essential part of basic medical training. The doctors and students surveyed also attached importance to the knowledge of how to tackle a whole set of disorders whose aetiology or whose effects are psychosocial (stress-related somatic disorders, emotional dif®culties associated with chronic or terminal illness, alcoholism and drug abuse), which also requires a familiarity with the social resources available to help patients. The topics which the doctors and students considered to be the most important corresponded broadly to those mentioned by doctors interviewed in various other surveys. Johnson and Snibbe6 in the United States and GuimoÂn et al.7 in Spain reported very similar

results. General practitioners and doctors responsible for undergraduate psychiatric training, interviewed by Callen8 in the United States, also stressed the importance of the doctor±patient relationship and interview techniques as well as the identi®cation of psychiatric problems. Again in the United States, doctors working in a variety of specialities, whether experienced or recent graduates, attached greatest importance to the doctor±patient relationship and psychosocial problems, followed by problems related to compliance and to psychosomatic disease9. The students and psychiatrists interviewed by Chatham-Showalter et al.11 also stressed the importance of knowing how to deal with the psychiatric problems of patients and learning the necessary interpersonal skills. In Switzerland, both the psychiatrists and the non-psychiatrists interviewed shared the same training objectives12. As the answers of physicians interviewed in our study corresponded overall to those

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Figure 1 The 10 most important psychiatric topics and the extent to which they were taught, according to students. Percentages of higher ratings (value 2±3 on scales 0±3).

obtained in other surveys, this would seem to con®rm that, even if the reply rate ± 44% ± was lower than the mean response rate for published mail surveys among doctors ± 54% ± with great variation according to subject studied and techniques used13, their replies concerning important psychiatric topics in medical practice were unbiased. The uniformity of the results obtained in these various studies carried out at different times (between 1975 and 1996), in different countries (United States, Spain, Switzerland), and on different subjects (students and doctors specializing in a variety of ®elds), points unequivocally to those essential areas of psychiatry that have the greatest bearing on general practice. Conversely, certain ®elds at the frontiers of psychiatric research, such as molecular biology and neuroimaging, and certain speci®c psychiatric techniques ± techniques for modifying behaviour, psychotherapy, psychoanalysis ± were only considered to be of limited importance. A few differences

The consensus between students and doctors with regard to the teaching of psychiatry to undergraduates is doubtless due to the fact that the students were all

reaching the end of their medical studies. As such, they were probably more concerned with the needs of their forthcoming medical practice than with the more technical aspects at the forefront of medical research. The few differences in the ratings observed (mainly problems associated with alcoholism and drug addiction), may well be related to this anticipation of the problems they would soon be facing in medical practice. It was found that the students gave a higher rating than the doctors to all items on the questionnaire. The insecurity brought about by their lack of experience, and their situation as students undergoing tests and required to send the questionnaire ± even anonymously ± to one of their teachers, may help to account for this fact. As the number of female medical students has greatly increased (at the present time over 50% of our medical students), it seemed important to obtain the opinions of both female and male students and doctors. Their opinions were very similar on the whole. However, the women tended to place greater emphasis on what may be called the relational±emotional sphere. Generally speaking, in the division of labour between the sexes, women tend to be more involved than men in the

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maintaining of interpersonal relations and female socialisation places emphasis on this point. Female doctors appear to attach more importance to certain interpersonal aspects of their profession than do their male colleagues. This greater importance is re¯ected, for example, in the longer consultation times recorded for female doctors14. Women doctors also express their desire to spend more time with their patients than do their male counterparts15. The importance that the female doctors attached to disorders concerning children and adolescents can be interpreted as re¯ecting the traditional role of women in the care and upbringing of children. Female doctors tend to favour different medical disciplines and a higher proportion of women than men tend to specialize in paediatrics. Among the doctors surveyed, 10% of the females were paediatricians vs. 5% of the males, and among the students 21% of the females were considering this speciality compared with only 6% of the males. Among the doctors questioned, it was mainly the primary-care doctors (general practitioners, internists, paediatricians) who expressed an interest in psychiatry. Frequently faced with complicated situations that they have to manage in the long term, these doctors are clearly aware of the need to develop their knowledge and skills, especially in the interpersonal sphere. Among the students, no such differences were noted with regard to subjects expressing an interest in psychiatry. There are various possible reasons for this lack of variation. This was a young group of people whose experience with patients was relatively uniform, and who had not yet had to deal with dif®cult and persistent problems of this type. They will eventually specialize in a variety of different ®elds and will not all become primary-care doctors like those with whom they were compared. Teaching

The students tended to give fairly low ratings overall. This was possibly a sign of a degree of concern over the hiatus that might exist between what is actually taught and what they assume will be needed in future practice. This unfavourable assessment may also be related to the place occupied by psychiatry among the various medical disciplines. Several studies have shown that, although psychiatry is often considered to be an important discipline for the future doctor, it is nevertheless seen as relatively imprecise and low in prestige. Daniel et al.10, repeating an earlier study, showed that 20 years on psychiatry continued to be seen as a poorly taught branch of medicine, and this is in spite of the many changes that have come about in psychiatric

training. Nevertheless, the proportion of respondents who considered that they had not acquired suf®cient psychiatric knowledge had fallen from 49% to 30% over this period.

Conclusion The teaching of psychiatry has to provide both basic training for students, whatever branch of medicine they will eventually specialize in, and suf®cient incentive to ensure that some will choose psychiatry as their speciality. The approach favoured by the respondents of our study, while of necessity including a number of specifically psychiatric aspects, underlines the importance of an insight into the social problems experienced by patients and of developing the interpersonal skills of the doctors. The very sharp rise in the number of women coming into medicine will no doubt place even more emphasis on this last point. Furthermore, some of the results of this study, and especially those concerning the needs of primary-care doctors, demonstrate the importance of increased psychiatric-type training at both the postgraduate and the vocational levels.

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647 14 Benzing JM, van den Brink-Muinen A, de Bakker DH. Gender differences in practice style: a Dutch study of practitioners. Med Care 1993;31:219±29. 15 Augsburger DoÈlle T, Frei R, Niklowitz M, Willi J. Die FoÈrderung der Einseitigkeit. KarrierewuÈnsche und Karrierehindernisse von Schweizer AÈrztinnen und AÈrzten. Bern: Verlag Hans Huber; 1996. Received 5 May 1998; editorial comments to authors 27 July 1998; accepted for publication 30 October 1998

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