Development of psychiatry curriculum as a major subject during MBBS in India

Abstract

Recently, psychiatry has been declared as a major subject in medical graduate curriculum at All India Institute of Medical Sciences, Rishikesh (AIIMS-Rishikesh), with separate examinations at the end of the seventh semester.[1] This necessitated a revamp of the existing curriculum at AIIMS-Rishikesh, in which psychiatry was seen as a section under the General Medicine curriculum, in line with the curriculum recently devised by the Medical Council of India (MCI).[2] This was also seen by the department as an opportunity to develop a robust curriculum which would further help in meeting the training needs of Indian Medical Graduates (IMGs). Innovation in medical education falls in the one of the mandates of AIIMS-Rishikesh. Process of deliberations Toward this end, for the development of curriculum, a process of expert consultation was evolved. For the purpose, a meeting (National Workshop for Undergraduate Curriculum of Psychiatry) was organized at AIIMS-Rishikesh under the aegis of the Indian Psychiatric Society (IPS), where members of IPS with ample experience in undergraduate teaching from all zones were approached. The aim of the meet was to discuss and deliberate upon the developments regarding undergraduate curriculum which could be applicable throughout India.[3] Those who agreed were allotted broad topics and were asked to develop a preliminary list of subtopics and competencies, as well as specifying suggested teaching and assessment methods. This list was collated. At the meeting held on 23–24 September 2019 at AIIMS-Rishikesh, separate sessions were devoted for discussions of individual broad topic areas. At each such session, the participants presented their approach to teaching in this topic area. Subsequently, deliberations were done among all participants to reach to a consensus on the content and the teaching methods to be used. Outcomes of deliberations are shown in Table 1.Table 1: Outcomes of the deliberations held at All India Institute of Medical Sciences, Rishikesh, for undergraduate curriculum in psychiatryDevelopment of undergraduate curriculum at All India Institute of Medical Sciences, Rishikesh In view of the recommendations from the group, AIIMS-Rishikesh has developed a curriculum to accommodate nearly 45 hours of theoretical teaching and about 4 weeks of clinical skills posting in psychiatry during the undergraduate training. This training would be followed by examination as a separate subject.[1] How the outcomes of deliberations were met? Generating interest toward psychiatry as a medical subject among IMG was one of the issues that was discussed in detail. A plethora of literature is available that shows that medical students either have negative or neutral attitude toward psychiatry and very few of them wish to pursue psychiatry as a career. One systematic review reported that main barriers toward opting psychiatry were challenges and efficacy of psychiatry as a medical branch, lack of scientific foundations of diseases and treatments, and loss of opportunity to use clinical skills.[4] Most of the students report that they would not be considered as “real doctor” and would lose skills learned during graduate years as a factor discouraging them to opt psychiatry.[5] Apathy toward psychiatry as a medical subject results from the perception of medical students that psychiatric disorders probably emerge out of 'excessive emotions' and 'loneliness'.[6] However, it has been shown that training during medical graduation improves knowledge regarding psychiatric disorders.[7] Members realized that new curriculum would be an opportunity to address these issues. Care was also taken to ensure that teaching methods would also be used appropriately to the content. A second aim of the choice of teaching methods was to sustain students' interest in the subject. In line with our current understanding of the nature of adult learning, this curriculum indicates topic areas that would be suitable for integrated teaching and suggests a range of large- and small-group teaching methods for delivery. Teaching focuses not just upon transferring information but also in the development of clinical skills, professional attitudes, and a deep understanding of medical ethics. With the understanding of the effectiveness of student-led learning for the retention of information, topics that are suitable for student seminars have also been specified. It was decided that teaching should consider conditions that would commonly be met with in general practice as per the current evidence from epidemiological studies and medical practice.[8] This has decided the current weightage of different disorders in curriculum, where substance use disorders and mood disorders were given more space as compared to less common psychotic disorders (available at https://drive.google.com/file/d/1ybo6B7zTpdYk0oZbl1×2Svz0CNhs-3ml/view?usp=sharing). Other conditions that are common in general practice and intricately related to psychiatry, but are not sufficiently addressed in the medical curriculum elsewhere, have also been included, e.g., sleep disorders.[910111213] The curriculum is designed to be in line with current international classification systems, including the Diagnostic and Statistical Manual-5 of the American Psychiatric Association and the International Classification of Diseases-11.[1415] These classification systems emphasize a medical model of psychiatric disorders, and it deemphasizes artificial distinctions between “organic” and “functional” disorders. It was felt that the use of such models would also be more congruent with IMGS' primary responsibilities as medical practitioners. Moreover, bio-psycho-social model is too complex to be taught during medical graduation as it is pillared on concepts of gene–environment interaction and neuroplasticity.[1617] This outcome is to be effected through the inclusion of relevant research during clinical and theoretical teaching. Social factors play an important role in all diseases including psychiatric disorders, thus, they have been given due weightage in the syllabus.[18] Most of the psychiatric disorders are diagnosed clinically. However, laboratory investigations are required for many purposes such as finding comorbid other medical disorders, assessing safety of pharmacotherapeutic agents before starting them, following up compliance to treatment, avoiding adverse effects, and diagnosing certain psychiatric disorders.[19] Moreover, functional neuroimaging is increasing recognized as an important tool in psychiatry research and management in recent past.[20212223242526] Thus, these techniques were included in the curriculum. In addition, certain other investigations that are available in institution, e.g., polysomnography, were also included in the curriculum. In defining competencies, the needs of the IMG as a generalist physician were placed at centerstage. In the proposed curriculum, as far as possible, expected competencies have been specified along with citations (wherever required). As far as possible, the extent and content of desired theoretical knowledge and clinical skills have been clearly specified. For example, curriculum mentions that IMG “should be able to elicit auditory hallucinations and paranoid delusions” during the training of Schizophrenia rather than mentioning “able to elicit sign and symptoms of psychosis” or “able to prescribe nicotine replacement therapy and follow-up patients nicotine replacement therapy” in nicotine use disorder. All efforts have been put to reduce ambiguity and duplication in all sections of the curriculum. This process was important as clear delineation of competencies ensures the development of a competent physician.[27] The curriculum also stresses a level of desired competence, in recognition of the fact that this curriculum does not represent the entirety of psychiatric knowledge. Experts recognized that curriculum should integrate with other subjects with regard to philosophy of syllabus, knowledge transfer, and modes of teaching. In such a case, within the subject need for inclusion of only prevalent, clinically important and prototype disorders were felt. Hence, in the proposed curriculum, among various categories, only selected disorders were emphasized. For example, in the area of sexual disorders, premature ejaculation and erectile dysfunction were included for detailed discussion; others, which are not likely to be encountered in clinical practice, have been excluded. Similarly, among psychotic disorders, schizophrenia was the prototype, and in sleep disorders, insomnia, obstructive sleep apnea, and insufficient sleep syndrome were selected for detailed discussion. Even in these disorders, specific aspects of the disorders that are pertinent to general practice and required for all the above objectives were included. For example, treatment of disorders was primarily focused on pharmacotherapy. However, counseling skills and a wide range of behavioral skills, which are important for all medical disorders and can be delivered competently by IMGs, are emphasized over intricate psychotherapeutic techniques. At the same time, redundancies and duplications should best be avoided by leaving scope for vertical as well horizontal integration of selected topics. This is the first model curriculum for training in UG psychiatry where the student writes a full 100 marks paper at the end of training. Having such an end point and thus needing an intensive curriculum in keeping with the mandates of the Department of Psychiatry at AIIMS is a major landmark in progress of UG Psychiatry Training in the country. The authors, who were also members of the workshop that debated on this curriculum, agree that the scope of training for UG psychiatry as per the current MCI curriculum may be different from what has been put together here. The authors also emphasize that “AIIMS-Rishikesh model” for psychiatry during under graduation could be used as a guide by other institutions in India after critical evaluation. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments We acknowledge the support and guidance provided by Dr. Murgesh Vaishanv, Dr. P K Dalal, Dr. Vinay Kumar, and Dr. Gautam Saha. We also acknowledge the following experts who attended meeting at AIIMS, Rishikesh. Mohan IssacDepartment of Psychiatry, University of Western Australia, WA, Australia.M KishorDepartment of Psychiatry, JSSMC, JSSAHER, Mysuru, Karnataka, India.MV AshokDepartment of Psychiatry, St. John's National Academy of Health Sciences, St. John's Medical College and Hospital, Bengaluru, Karnataka, India.Om Prakash SinghEditor, Indian Journal of Psychiatry.Rakesh Kumar ChaddaDepartment of Psychiatry, AIIMS, New Delhi.PK SinghDepartment of Psychiatry, Patna Medical College, Patna, Bihar, India.Henal ShahDepartment of Psychiatry, TN Medical College, Mumbai, Maharashtra, India.Vinay HRDepartment of Psychiatry, Adichunchanagiri Institute of Medical Sciences, Mandya, Karnataka, India.Pankaj KumarDepartment of Psychiatry, AIIMS, Patna.Mukesh Swami, Naresh NebhinaniDepartment of Psychiatry, AIIMS, Jodhpur.Rajat RayFormer Professor, AIIMS, New Delhi.Vikas MenonDepartment of Psychiatry, JIPMER, Pondicherry, India; Contribution in Absentia, India.Suhas ChandranContribution in Absentia.