Directors of postgraduate internal medicine programs face many problems in program design, particularly when numbers of house staff continue to decrease. This paper examines the training requirements of a resident in internal medicine and proposes a curriculum based on set rotations in the three key areas of training--subspecialty services, critical care and the clinical teaching unit. The distribution of time in these three areas and the balance of exposure to inpatients and outpatients are discussed in detail. This program design ensures exposure to all the key elements of internal medicine in 3 years and should prevent significant gaps in knowledge at the time of certification. The implications for "service" in major teaching hospitals is discussed. Hospital departments and administrators must confront the prospect of hospital units without house staff. Most important, program directors must resist sacrificing the pedagogic essentials of a training program for service requirements.
Unhealthy lifestyle choices frequently cause or worsen chronic diseases. Many internal medicine residents are inadequately trained to provide effective health behavior counseling, in part, due to prioritization of acute care in the traditional model of medical education and to other systemic barriers to teaching psychosocial aspects of patient care.
To address this gap in training, we developed and piloted a curriculum for a Primary Care Internal Medicine residency program that links a practical form of motivational interviewing (MI) training to the self-management support (SMS) component of the chronic care model.
PARTICIPANTS AND SETTING
All 30 primary care residents at Alameda County Medical Center were trained in the curriculum since it was initiated in 2007 during the California Academic Chronic Care Collaborative.
Residents participated in three modules during which the chronic care model was introduced and motivational interviewing skills were linked to the model’s self-management support component. This training was then reinforced in the clinical setting. Case-based interactive instruction, teaching videotapes, group role-plays, faculty demonstration, and observation of resident-patient interactions in the clinical setting were used to teach the curriculum.
A preliminary, qualitative assessment of this curriculum was done from a program standpoint and from the perspective of the learners. Residents reported increased sense of confidence when approaching patients about health behavior change. Faculty directly observed residents during clinical encounters using MI and SMS skills to work more collaboratively with patients and to improve patient readiness for self-management goal setting.
A curriculum that links motivational interviewing skills to the chronic care model’s self-management support component and is reinforced in the clinical setting is feasible to develop and implement. This curriculum may improve residents’ confidence with health behavior counseling and with preparing patients to become active participants in management of their chronic conditions.
chronic care model; self-management support; motivational interviewing; residency training; primary care
The provision of quality out-patient psychiatric care to a predominately black inner-city population, in a University setting such as ours, is a complex and challenging task. This paper addresses service and teaching issues related to the provision of that care in the Adult Unit of the Howard University Hospital Mental Health Clinic. In this setting there is a mandate for clinical teaching and research as well, two vital components in the delivery of quality psychiatric service by knowledgeable and skilled health care providers.
Teaching the content of clinical practice guidelines (CPGs) is important to both clinical care and graduate medical education. The objective of this study was to determine the characteristics of curricula for teaching the content of CPGs in family medicine and internal medicine residency programs in the United States.
We surveyed the directors of family medicine and internal medicine residency programs in the United States. The questionnaire included questions about the characteristics of the teaching of CPGs: goals and objectives, educational activities, evaluation, aspects of CPGs that the program teaches, the methods of making texts of CPGs available to residents, and the major barriers to teaching CPGs.
Of 434 programs responding (out of 839, 52%), 14% percent reported having written goals and objectives related to teaching CPGs. The most frequently taught aspect was the content of specific CPGs (76%). The top two educational strategies used were didactic sessions (76%) and journal clubs (64%). Auditing for adherence by residents was the primary evaluation strategy (44%), although 36% of program directors conducted no evaluation. Programs made texts of CPGs available to residents most commonly in the form of paper copies (54%) while the most important barrier was time constraints on faculty (56%).
Residency programs teach different aspects of CPGs to varying degrees, and the majority uses educational strategies not supported by research evidence.
OBJECTIVE: To assess whether the mental health component of the family medicine residency program at Memorial University of Newfoundland, which contains no formal mental health training with psychiatrists, adequately prepares residents for practice, and to assess which aspects of their training enhanced their mental health skills most. DESIGN: Cross-sectional mailed survey. SETTING: A 2-year family practice residency program with a focus on training for rural practice offering integrated and eclectic multidisciplinary mental health training rather than formal psychiatry experience. PARTICIPANTS: Graduates of the family practice residency program, 1990 to 1995. Completed questionnaires were returned by 62 of 116 physicians. MAIN OUTCOME MEASURE: Confidence of respondents in dealing with 23 mental health problems. RESULTS: Respondents felt prepared to address most of the mental health needs of their patients. Higher levels of confidence were associated with lower referral rates. There was no significant relationship between time spent in practice and confidence in dealing with mental health problems. Graduates' confidence correlated with areas in the program identified as strong. CONCLUSIONS: The program appears to train family doctors effectively to meet the mental health needs of their patients.
For decades, films across the world have entertained people and affected their attitudes regarding certain issues and conditions. Documentary films have been used by governments in different parts of the world to educate the general public and promote health and prevent the spread of disease as part of public health programs. Psychiatry as a branch of medicine like the rest of medicine continues to develop. With an increasing awareness among the general population and popularity of films showing various aspects of mental illnesses on the rise, educators and teachers are turning their attention to using films for education of medical students and psychiatric trainees. Although films may be stereotypical and prejudiced, they can be used successfully in teaching psychiatry trainees. In this paper, development of a movie club and its use are described and suggestions made to improve the use of films in this process.
Cinema; films; resident training; teaching
Family physicians may spend up to 50% of their time diagnosing and managing mental disorders and emotional problems, but this is not always reflected in the training they receive. This study of the teaching of psychiatry in the 16 family medicine residency programs in Canada showed that although the majority of program directors are reasonably satisfied with the current training, they see room for improvement—particularly in finding psychiatrists with a better understanding of family practice, in integrating the teaching to a greater degree with clinical work, thereby increasing its relevance, and in utilizing more suitable clinical settings.
residency training; psychiatry; family medicine
Smokers with mental illness and addictive disorders account for nearly one in two cigarettes sold in the United States and are at high risk for smoking-related deaths and disability. Psychiatry residency programs provide a unique arena for disseminating tobacco treatment guidelines, influencing professional norms, and increasing access to tobacco cessation services among smokers with mental illness. The current study evaluated the Rx for Change in Psychiatry curriculum, developed for psychiatry residency programs and focused on identifying and treating tobacco dependence among individuals with mental illness.
The 4-hour curriculum emphasized evidence-based, patient-oriented cessation treatments relevant for all tobacco users, including those not yet ready to quit. The curriculum was informed by comprehensive literature review, consultation with an expert advisory group, faculty interviews, and a focus group with psychiatry residents. This study reports on evaluation of the curriculum in 2005–2006, using a quasi-experimental design, with 55 residents in three psychiatry residency training programs in Northern California.
The curriculum was associated with improvements in psychiatry residents’ knowledge, attitudes, confidence, and counseling behaviors for treating tobacco use among their patients, with initial changes from pre- to posttraining sustained at 3-months’ follow-up. Residents’ self-reported changes in treating patients’ tobacco use were substantiated through systematic chart review.
The evidence-based Rx for Change in Psychiatry curriculum is offered as a model tobacco treatment curriculum that can be implemented in psychiatry residency training programs and disseminated widely, thereby effectively reaching a vulnerable and costly population of smokers.
The specialist psychiatric services available in India is insufficient to meet the mental health needs of the country. Training of general practitioners in psychiatry through short courses is one of the remedial strategies. In 1982-83, an ICMR Multi-Centre Project of Training in Psychiatry for Non-Psychiatrist Primary Care Doctors was successfully completed at Bangalore, Hyderabad and Vellore using the training methods developed at NIMHANS. This paper describes the training programme and the results.
Moving in early career from public health physician to psychiatrist gives me a public health view of psychiatry and an interest in pursuing the goals of widening access to community-based services for people with mental disorders and promoting mental health in communities. Training in social medicine in the UK and psychiatry in Australia lead to studies of homelessness in people living with psychotic disorders, the health of family caregivers, assessing quality of life and mental health promotion.
Work with the World Health Organization (WHO) in the Western Pacific Region and the World Psychiatric Association (WPA) worldwide has given me opportunities to work with psychiatrists, mental health workers, service users and others in governments and non-government organisations implementing the recommendations of the World Health Report 2001 in countries with limited resources. My work as WPA Secretary for Publications seeks to improve information exchange in countries irrespective of their wealth. This is an exciting time to be working in a global village with technical capacity to reach into its furthest corners. Psychiatrists supported by WPA can help ensure that vulnerable people and communities and people living with mental disorders are well served in this new environment and no longer left out and left behind.
Public health; social medicine; health promotion; research dissemination; economic development
This study evaluated parents’ experience with University of Massachusetts (UMass) Child Psychiatry Access Project (MCPAP), a consultation service to primary care providers (PCP), aimed at improving access to child psychiatry. Parent satisfaction questionnaire was sent to families referred to UMass MCPAP by their PCP, asking about their concerns leading to the referral, the satisfaction from the service provided, adequacy of the follow up plan, and outcome. Seventy-nine percent of parents agreed or strongly agreed that the services provided were offered in a timely manner. Fifty percent agreed or strongly agreed that their child’s situation improved following their contact with the services. Sixty-nine percent agreed or strongly agreed that the service met their family’s need. The results suggest moderate to high parental satisfaction with MCPAP model, but highlight ongoing challenges in making successful referrals for children’s mental health services in the community, following MCPAP recommendations.
child psychiatry; primary care; consultation liaison; parent satisfaction
America experienced a genuinely vast development of biomedical science in the early decades of the twentieth century, which in turn impacted the community of academic psychiatry and changed the way in which clinical and basic research approaches in psychiatry were conceptualized. This development was largely based on the restructuring of research universities in both of the USA and Canada following the influential report of Johns Hopkins-trained science administrator and politician Abraham Flexner (1866–1959). Flexner's report written in commission for the Carnegie Foundation for the Advancement of Teaching in Washington, DC, also had a major influence on complementary and alternative medicine (CAM) in psychiatry throughout the 20th century. This paper explores the lasting impact of Flexner's research published on modern medicine and particularly on what he interpreted as the various forms of health care and psychiatric treatment that appeared to compete with the paradigm of biomedicine. We will particularly draw attention to the serious effects of the closing of so many CAM-oriented hospitals, colleges, and medical teaching programs following to the publication of the Flexner Report in 1910.
Psychiatric services remained virtually unknown in Nepal until 1961. The first psychiatric outpatient service was started in 1961, at Bir Hospital, Kathmandu. In 1984, the Psychiatry Department at Bir Hospital was separated and a mental hospital was created, which was later shifted to its current location at Lagankhel, Patan, in Kathmandu valley, in 1985. It is the only mental hospital in Nepal with a current bed strength of 50 beds. The new era in medical learning and teaching was ushered in Nepal with the establishment of the Institute of Medicine (IOM) under the Tribhuban University and the 400-bed Tribhuban University-Teaching Hospital (TU-Teaching Hospital), in the year 1983. BP Koirala Institute of Health Sciences (BPKIHS) at Dharan was established in 1993, as a part of the joint Indo–Nepal collaboration on developing an international standard teaching, training, and research-oriented medical institute similar to AIIMS, New Delhi. During the last one-and-half decades a number of privately run medical colleges have come up in Nepal. Outpatient and inpatient Psychiatry Departments have been established in most of these government as well as private medical institutes. At present, the postgraduate course (MD) in psychiatry has been running in two government-run institutes as well as three privately run medical colleges. Indian psychiatrists have played and are still playing significant roles in establishing as well as maintaining Psychiatry Departments, especially in the private sector medical colleges. They have also contributed to the growth of psychiatry research and postgraduate teaching in psychiatry, in Nepal.
India; Nepal; psychiatry
Psychiatry training programs provide a unique arena for affecting professional norms and increasing access to tobacco cessation services among smokers with mental illness. Psychiatry Rx for Change emphasizes evidence-based patient-oriented tobacco treatments relevant for tobacco users with psychiatric disorders. Following Diffusion of Innovations theory and the RE-AIM framework, the curriculum is being disseminated to psychiatry residency and graduate psychiatric nursing programs in the Western United States with plans to study curriculum adoption, implementation, and maintenance on a broad scale. Psychiatry Rx for Change aims to increase the likelihood that smokers with co-occurring disorders will receive evidence-based cessation treatment.
tobacco; nicotine dependence; education; training; dissemination
The purpose of this study was to determine resident satisfaction with an acute care psychiatric clinic designed in collaboration with a nearby community mental health center. We also sought to demonstrate that this rotation helps meet program requirements for emergency psychiatry training, provides direct assessments of resident interviewing skills and clinical knowledge in the postgraduate year-1, and provides exposure to public sector systems of care.
We developed a resident satisfaction questionnaire and fielded it to each of the residents who participated in the clinic over the first 3 years. Data were collected, organized, and analyzed.
Of the 15 residents in the acute care psychiatric clinic, 12 completed and returned the satisfaction questionnaires. Educational aspects of the clinic experience were rated favorably.
This postgraduate year-1 acute care psychiatric clinic provides a mechanism for the fulfillment of emergency psychiatry training as well as direct supervision of clinical encounters, which is a satisfactory and useful educational experience for trainees.
Seasonal and monthly variations in utilization of psychiatric services have been inadequately studied in India.
This study sought to determine the pattern of psychiatric services utilization by patients with four broad categories of diagnosis (mood disorders (F30-39): neurotic stress-related and somatoform disorders (F40-48), schizophrenia, schizotypal and delusional disorders (F20-29) and mental and behavioral disorders due to psychoactive substance use (F10-19) in different seasons and months of the last six years.
Materials and Methods:
We conducted a teaching hospital data-based study of new patients diagnosed with psychiatric illness in the department of psychiatry, Government Medical College and Hospital, Chandigarh. Four diagnostic groups consisting of 12058 psychiatric patients who had been diagnosed and treated in the department of psychiatry of this institute from 1999-2004 were included in this evaluation. Bed occupancy rate (BOR), average length of stay (ALOS) of inpatients and seasonal index were determined. Information about weather variables (mean daily temperature, mean rainfall) was collected from the meterological department of Chandigarh.
Psychiatric services were utilized by 31.1% of patients with mood disorders in the summer and by 34.23% of patients with neurotic, stress-related and somatoform disorders in the autumn. Statistical analysis revealed significant difference in new cases of these two groups of disorders in different seasons.
Our study showed a significant relationship between utilization of psychiatric patients especially with mood disorders and neurotic, stress related and somatoform disorders with season (summer and autumn respectively).
Mental and behavioral disorders due to psychoactive substance use; mood disorders; neurotic stress-related and somatoform disorders; schizophrenia; schizotypal and delusional disorders
It is challenging to create an educational and satisfying experience in the outpatient setting. We developed a 3-year ambulatory curriculum that addresses the special needs of our categorical medicine residents with distinct learning objectives for each year of training and clinical experiences and didactic sessions to meet these goals. All PGY1 residents spend 1 month on a general medicine ambulatory care rotation. PGY2 residents spend 3 months on an ambulatory block focusing on 8 core medicine subspecialties. Third-year residents spend 2 months on an advanced ambulatory rotation. The curriculum was started in July 2000 and has been highly regarded by the house staff, with statistically significant improvements in the PGY2 and PGY3 evaluation scores. By enhancing outpatient clinical teaching and didactics with an emphasis on the specific needs of our residents, we have been able to reframe the thinking and attitudes of a group of inpatient-oriented residents.
medical education; residency training; ambulatory medicine
The impact of managed care in the 1990s and the need for more broadly trained primary care physicians led the American Board of Internal Medicine and the American Board of Family Practice to explore ways to collaboratively train primary care physicians. One proposed solution was a combined residency incorporating the training curriculums of both boards in an integrated fashion. In 1995, the Alton Ochsner Medical Foundation Combined Family Practice and Internal Medicine Residency Program was one of the first to be approved by the two boards. The first residents began training in July 1996. Due to overlap in curriculums, completion for both boards is possible in 48 months as opposed to the 72 months a consecutive approach would require. The first graduates completed the program in July 2000.
The combined residents rotate on both the Family Practice inpatient service and the General Internal Medicine wards and participate in continuity care clinics and precepting in both core programs. Facilities for the program involve only existing clinics and administrative personnel. Residents serve as primary care physicians for a mixed ethnic, middle-class patient population atOchsner's New Orleans East satellite clinic, provide longitudinal obstetric and pediatric care at an inner city clinic, and complete a rural primary care rotation. Inservice examination scores have been consistently high with several combined residents scoring at the top United States level on both examinations. The program has matched with our highest ranked students over each year of the program despite a marked decline in US graduates entering primary care fields. Graduates of the combined program are ideal staff for either medical schools or residency programs of either core program.
While this residency is in its early stages, both boards have mandated an indepth evaluation to determine the quality and outcomes of training. The results of a recent survey of current Ochsner residents assessing their perceptions of the combined program were encouraging. We plan to track our graduates and compare them with recent graduates of the two core programs in order to document long-term impact.
The Family Medicine Residency Program at the University of Alberta has used academic sessions and clinical-based teaching to prepare residents for private practice. Before the new curriculum, academic sessions were large group lectures given by specialists. These sessions lacked consistent quality, structured topics, and organization.
OBJECTIVE OF PROGRAM
The program was designed to improve the quality and consistency of academic sessions by creating a new curriculum. The goals for the new curriculum included improved organizational structure, improved satisfaction from the participants, improved resident knowledge and confidence in key areas of family medicine, and improved performance on licensing examinations.
The new curriculum is faculty guided but resident organized. Twenty-three core topics in family medicine are covered during a 2-year rotating curriculum. Several small group activities, including problem-based learning modules, journal club, and examination preparation sessions, complement larger didactic sessions. A multiple-source evaluation process is an essential component of this new program.
The new academic curriculum for family medicine residents is based on a variety of learning styles and is consistent with the principles of adult learning theory. This structured curriculum provides a good basis for further development. Other programs across the country might want to incorporate these ideas into their current programming.
Since 2005, Kenyan medical universities have been training general practitioners, providing them with clinical, management, teaching and research skills, in order to enhance access to and quality of health care services for the Kenyan population. This study assesses what expectations family physicians, colleagues of family physicians and policy makers have of family medicine, what expectations family physicians live up to and which challenges they face.
Family physicians were observed and interviewed about their expectations and challenges concerning family medicine. Expectations among their colleagues were assessed through focus group discussions. Policy makers’ expectations were assessed by analysing the governmental policy on family medicine and a university’s curriculum.
Roles perceived for and performed by family physicians included providing comprehensive care, health care management, teaching, and to a lesser extent community outreach and performing research. Challenges faced by family physicians were being posted in situations where they are regarded as just another type of specialist, lack of awareness of the roles of family physicians among colleagues, lack of time, lack of funds and inadequate training.
The ministry’s posting policy has to be improved to ensure that family physicians have a chance to perform their intended roles. Creating an environment in which family physicians can function best requires more effort to enlighten other players in the health care system, like colleagues and policy makers, about the roles of family physicians.
Core content in family medicine has been difficult to define, given that family practice has differed widely from physician to physician, according to locale and availability of resources. Since family medicine has been taught, educators have been attempting to define its core content—and find ways of teaching it. At the McMaster University Medical Centre Family Practice Unit we have put the problems first: residents present a problem in patient care and the group discusses the problem in relation to a precirculated article on the topic. Lecturing is kept to a minimum, and articles are chosen according to the principles of critical appraisal. An attempt at evaluation generated a positive response.
Core content; teaching; problem-based learning
This article summarises the findings of recent priority setting exercises for psychiatric research and of a mapping of research capacity and resources in south Asia. The priorities for research in the region, as in other developing countries, are related to ‘implementation’ science, i.e. the field of inquiry investigating acceptable and affordable methods of delivering effective treatments for mental disorders, which aims to help close the large treatment gap. “Discovery” research which aims to strengthen our understanding of the nature of mental disorders through well-designed epidemiological and descriptive clinical studies, and expand the armamentarium of effective treatments by mapping and evaluating indigenous approaches to mental health care is also an important priority. However, research capacity and resources in the region are scarce and need strengthening by action from diverse stakeholders including the Indian Psychiatric Society.
Research priorities; research capacity; implementation science; epidemiology
Medicine has developed sophisticated technologies based on an extensive knowledge base but it has met with serious application obstacles. Where prevention data is available, implementation of preventive measures faces great difficulty. Where compliance with treatment is found to improve outcome, ways to improve compliance have to be found. Although behavioral medicine has produced efficient learning based strategies for helping people modify their potentially noxious habits and even their environment, it cannot influence motivation to change. Information raises motivation and informing is the task of health education. The present paper presents three applications of SIC**, a microcomputer based patient teaching aid developed in response to the need for an unobtrusive, cost-efficient and flexible vehicle for transmitting clinically relevant information to target populations in a programmerless environment. Examples in mental health and psychosomatic medicine are presented and implication for future research is discussed.
The Accreditation Council for Graduate Medical Education (ACGME) requirements stipulate that psychiatry residents need to be educated in the area of emergency psychiatry. Existing research investigating the current state of this training is limited, and no research to date has assessed whether the ACGME Residency Review Committee requirements for psychiatry residency training are followed by psychiatry residency training programs.
We administered, to chief resident attendees of a national leadership conference, a 24‐item paper survey on the types and amount of emergency psychiatry training provided by their psychiatric residency training programs. Descriptive statistics were used in the analysis.
Of 154 surveys distributed, 111 were returned (72% response rate). Nearly one‐third of chief resident respondents indicated that more than 50% of their program's emergency psychiatry training was provided during on‐call periods. A minority indicated that they were aware of the ACGME program requirements for emergency psychiatry training. While training in emergency psychiatry occurred in many programs through rotations—different from the on‐call period—direct supervision was available during on‐call training only about one‐third of the time.
The findings suggest that about one‐third of psychiatry residency training programs do not adhere to the ACGME standards for emergency psychiatry training. Enhanced knowledge of the ACGME requirements may enhance psychiatry residents' understanding on how their programs are fulfilling the need for more emergency psychiatry training. Alternative settings to the on‐call period for emergency psychiatry training are more likely to provide for direct supervision.
Family practice obstetricians are an endangered species. Our practices and teaching sites must provide the correct attitudinal as well as technical messages to result in a practitioner who will be able to meet the psychosocial and medical needs of the pregnant couple. Family practice obstetrics can be as safe as care given by obstetricians provided that the family practice group functions well, that obstetrical consultants are available and supportive, and assuming that technical approaches are reserved for those truly in need. In rural areas, obstetrical ability is essential, whilst in the urban setting it helps the family physician maintain a practice involving young families. Those trainees who fail to learn basic obstetrical skills (including family centered attitudes and approaches) may in any setting come to feel, belatedly, that their training programs failed in this respect.