Abstract
Undergraduate medical education in psychiatry and behavioural science has burgeoned in recent decades. In the United States, for example, the number of hours devoted to psychiatry in medical schools quadrupled in the 40 years following World War II. As part of this growth, teaching extended from clinical to pre-clinical years, methods of teaching were updated and new subspecialities were added to curricula [1]. Australian and New Zealand medical schools have followed suit, although details of teaching practices have never previously been collated in sufficient detail to permit comparison.
Whether departments of psychiatry use this increased time to best advantage remains open to question. Ney and Jones [2] asserted that teaching allocations had as much to do with academic imperialism as with students’ perceived needs, and Vioneskos [1] expressed concern that the patients encountered by students in most university teaching hospitals had little in common with those they would care for later in their careers.
Sadly, there is little discussion in the mental health literature, or at national or international meetings, of issues relating to the content and format of undergraduate tuition in psychological medicine. A Medline search using the key words ‘medical education, undergraduate’ and ‘psychiatry’ of English-language papers published between 1980 and 1995 generated 53 reports of which 27 addressed students’ attitudes to psychiatry, eight concerned evaluation and examination, three discussed student's wellbeing while on clinical placement and four were general reviews. Only 11 provided details of actual teaching practices.
The study described here of the content, timing and format of psychiatric tuition in all 12 Australian and New Zealand medical schools was sparked by an interest in how teaching in our own university compared with that in others. Clearly, the quality of teaching is more important than quantity. It cannot be assumed that a university which offers twice as much teaching as another produces students with twice the depth of knowledge or twice the level of skill, but gauging quality is so difficult, even within a single institution, that we focused instead on those aspects of teaching that can be quantified in a reasonably reliable and valid fashion.
At the time of the study, 11 of the 12 medical schools offered a traditional 6-year course and one had a 5-year course. Three are moving at present to shorter postgraduate programs with the result that our data represent a snapshot view of a rapidly changing system. We hope nonetheless that the data presented here will stimulate discussion and consideration of teaching practices in Australia and New Zealand in the light of future doctors’ needs and current best educational practice.
Method
A 23-page structured questionnaire was devised, complete with definitions of terms and coding instructions, inquiring into the teaching delivered to medical students by members, either salaried or honorary, of university departments of psychiatry or psychological medicine. The questionnaire covered: hours of tuition to each class; hours of part-class teaching (e.g. tutorials), whole-class teaching (e.g. lectures) and clinical attachments; types and locations of clinical attachments; completed student options and electives; contacts with non-psychiatric mental health practitioners and advocates; contact with representatives of Maori, Aboriginal and non-English-speaking-background (NESB) communities; formal teaching of psychiatric history taking, mental state examination, major psychiatric syndromes and subspecialties; formal teaching of psychological and somatic therapies; the number and types of student examinations, and the number and types of teaching evaluations. The questionnaire was vetted by colleagues in both countries and went through numerous drafts.
The heads of department of all 12 medical schools in Australia and New Zealand agreed to participate in the survey. Questionnaires were distributed in 1996 to department heads and, through them, to class coordinators (the three schools which had more than one clinical department were allowed to choose which department was represented in the survey). Coordinators were asked to give details of the teaching offered in 1995 unless major changes had occurred in which case 1996 was surveyed instead. Once returned, all forms were checked by the authors who clarified missing, incomplete or inconsistent data with coordinators. As a final check, a draft report was circulated to schools for comment and verification.
Results
Distribution of teaching in course
Tables 1 and 2 list the numbers of years taught by the 12 departments and the classes to which teaching was offered. Nine of the 12 contributed to pre-clinical programs but only four provided tuition to every available class. All pre-clinical teaching was offered in conjunction with other departments, most notably general practice, public health and psychology. Other less common collaborators included departments of medicine, paediatrics, obstetrics and gynaecology, medical genetics, pharmacology and philosophy.
The total amount of teaching provided by departments ranged from 285 to 534 h with a mean of 416 h. But, because pre-clinical teaching was not provided uniformly, the results which follow are confined to clinical tuition (i.e. the teaching of psychiatric history taking, mental state examination, psychiatric diagnosis and biological and psychological therapies). Teaching thus defined was offered to as few as 1 year, and as many as 4, with a mean of 2.9 years (Table 3, column 1). The quantum of clinical tuition, including attachments to hospitals, clinics and the like, ranged from 279 to 454 h with a mean of 353 h (Table 3, column 2).
Number of years taught by departments of psychiatry
Stages of course taught by departments of psychiatry
Teaching format
Clinical attachments occupied the bulk of teaching time (mean 70%), followed by part-class tuition in the form of tutorials and seminars (mean = 19%) and whole-class tuition, mostly in the form of lectures (mean = 11%) (Table 3, columns 3–5). Two departments offered no or very few lectures and none devoted more than a third of available time to this modality.
Total hours of clinical attachments ranged from 160 to 318 with a mean of 246 h (Table 3, column 5). Seven departments offered two discrete attachments, one or two years apart. Students were dispersed mostly to adult acute inpatient facilities. Child psychiatry attachments were offered to all students in two universities and to some in another three. Aged psychiatry was offered to all students in two universities and to some in another six, possibly because of the greater availability of inpatient units. Exposure to alcohol and drug treatment programs was equally patchy, occurring for all of the students in three universities and a proportion in three more. Seven universities attached no students to child psychiatry, four attached none to aged psychiatry and six attached none to alcohol and drug programs.
Student attachments were mostly to public, metropolitan psychiatric facilities. Only six departments collaborated with private hospitals and only six made use of country facilities.
Duration, content, specialty attachments and examinations of clinical teaching
Teaching content
Much teaching took place within clinical attachments and was therefore hidden from view (the data presented here concern programmed teaching which could be documented with reasonable accuracy). With this proviso in mind, we enquired about teaching content in the areas of psychiatric history taking and mental state examination, major psychiatric syndromes, subspecialties and therapies (see Table 3, columns 6–14).
Hours of formal teaching to all students in history taking and mental state examination ranged from 5 to 49 h, with a mean of 23 h (Table 3, column 6), largely in the form of tutorials and other part-class methods (mean = 74%). Eleven departments had students observe tutors conducting interviews and vice versa, six used videotapes of interviews and one employed actors to mimic patients with mental disorders.
It was of interest to note the priorities attached to particular psychiatric syndromes. To demonstrate this, formal time allocations are presented in four domains: schizophrenia and related psychoses, depression, alcohol and substance use disorders and somatoform disorders (Table 3, columns 7–10). Overall, alcohol and substance use received the greatest attention and somatoform disorders the least, but allocations varied widely. The time devoted to schizophrenia ranged from 0.5 to 14 h, depression from 0.5 to 15 h, alcohol and drug use from one to 35 h, and somatoform disorders from 1 to 8 h.
With respect to subspecialties, times allocated to child psychiatry ranged from 3 to 43 h and to aged psychiatry from 0 to 8 h (Table 3, columns 11–12).
Psychological therapies, defined broadly as relaxation training, counselling, psychotherapy, behaviour therapy, cognitive therapy and family therapy, were taught formally for between 1 and 17 h. Timetabled tuition in particular treatment types was as follows: relaxation training, 0 to 1 h (mean = 0.5); counselling, 0.5 to 4 h (mean = 1.6); behavioural and/or cognitive therapy, 0 to 8.25 h (mean = 2.1) and family therapy 0 to 2.25 h (mean = 0.7). Two departments offered no teaching on relaxation training, one offered none on counselling, one none on cognitive or behavioural therapy and six none on family therapy.
Teaching on somatic treatments (pharmacotherapy and electroconvulsive therapy) ranged from 3.5 to 10 h (mean = 7.0).
Seven departments had offered options or electives in psychiatry in clinical years. Seven exposed students to representatives of non-medical support or advocacy groups (e.g. Schizophrenia Fellowship), three provided contact with members of Aboriginal, Maori or Pacific Island communities and five offered teaching on mental disorder in persons from non-English-speaking backgrounds.
Student examinations
The number of examinations of students’ clinical knowledge and skills in psychiatry ranged from two to nine per department with a mean of 5.2 (Table 3, column 15). There was great diversity in the choice of test technique: multiple choice papers accounted for 8% of assessments; objective structured clinical examinations (OSCEs) for 13%; written clinical case reports for 23%; verbal case presentations for 24%, and essays for 32%.
Teaching evaluation
Students were asked to evaluate 28 of the 35 clinical classes considered here (80%). Most non-evaluated courses were so brief (mean = 12 h, range = 4–32 h), and so dominated by other departments, that evaluation was probably of dubious value. An independent audit of teaching quality was conducted by a medical educationalist in a single class at one university.
Discussion
Our findings must be interpreted cautiously for two reasons. First, we can comment only on the quantity, not the quality, of teaching on offer in Australasian universities in 1995 and 1996. Of the two, the quality of tuition is by far the more important. One hour of enthusiastic teaching with clearly articulated goals and a strong clinical focus is generally preferable to a series of rambling, uninspired lectures on abstruse topics, but quality is so difficult to measure, even within a single institution, that we made no attempt to do so.
Second, a brief postal survey of teaching offered in 50 pre-clinical and clinical years must inevitably be superficial. We have doubtless overlooked much teaching provided by members of other departments on topics relevant to psychological medicine as well as the potentially invaluable tuition provided by clinical staff during attachments to hospitals, clinics and community teams. Our findings should be supplemented, therefore, by more detailed studies of educational practices in specialist domains like those conducted previously in Britain and the United States of teaching in child psychiatry [3], consultation-liaison psychiatry [4, 4, 5]] and alcohol and substance abuse [6].
Despite these limitations, the use of structured questionnaires and intensive data verification mean that we can make some reasonably valid comparisons between universities. Of interest is the wide variation in the amount of teaching offered. One department contributed to only two of its school's 6-year course, while others contributed to every available year. As a result, the most active department had almost twice as many student contact hours as the most parsimonious. It would be interesting to know more of the reasons for such discrepancies and of their consequences for staff numbers, staff activities, postgraduate tuition and research.
Despite these variations, a number of common themes and practices emerged. Clinical attachments were clearly the preferred means of tuition in all universities, supplemented by small group teaching and few (if any) lectures. Clinical attachments were most commonly to public adult inpatient units, and less commonly to child or aged psychiatry units, alcohol and drug treatment clinics, consultation-liaison services, private hospitals, rural services or primary care.
Although teaching in some of these domains may occur elsewhere in the curriculum, an excessive focus on public adult psychiatry brings with it a risk that students will graduate without substantial exposure to the mood disorders, anxiety disorders, substance abuse and cognitive impairment that constitute the bulk of psychopathology encountered in the community [7]. The recent report of a joint committee of the Royal Australian College of General Practitioners and the Royal Australian and New Zealand College of Psychiatrists highlighted the need for general practitioners to be competent in a range of psychiatric and psychological disorders including fatigue and unexplained physical symptoms which students are more likely to meet in primary care and general medical wards than psychiatric inpatient units [8].
Given the lack of a ‘gold standard’, it is impossible at present to deduce exactly what type and amount of teaching is ideal. In theory, curricula should be based on a detailed analysis of the knowledge and skills required by future general practitioners, physicians and surgeons. The time devoted to mental health should certainly be substantial since as many as 9% of general practice consultations in Australia relate directly to mental, emotional and behavioural concerns [9]. In addition, much psychopathology is hidden from view. In one North American survey, only 6% of persons with mental disorder had sought help in the previous year from a specialist psychiatric or addictive service [10]. General practitioners will continue to manage the majority of mental health problems, many of which arise in conjunction with physical illness and disability, and they must be trained to provide this care as effectively and humanely as possible.
Since all clinicians should know, for example, how to gauge the risk of suicide, how to elicit details of a patient's alcohol and drug consumption and when to prescribe antidepressant medication, such skills should form a part of the core undergraduate curriculum. But exactly how much teaching should be offered remains open to question, not least because of current and continuing changes in service delivery models. In former times, thoughtful curriculum planners would probably have focused on the common mental conditions mentioned already: affective and anxiety disorders, substance abuse and dementia. However, with the move to ‘shared care’, general practitioners will be asked to contribute actively to the medical and psychiatric care of patients with severe, persistent psychoses who reside in the community [8]. This shift in clinical practice must be borne in mind by undergraduate tutors but, whatever the outcome, an almost exclusive exposure to patients hospitalised because of a worsening of their psychosis cannot provide students with sufficient knowledge and experience to equip them for their future careers.
Perhaps the most worrying finding concerns the very small number of hours devoted to counselling and other psychological therapies. General practitioners make it clear that discussions designed to help patients ventilate uncomfortable emotions and assess options in lifestyle occupy a substantial part of their working day [8]. A number of universities now offer teaching in ‘communication skills’ which emphasise active attention, open-ended questioning and reflectiveness. These skills form the basis of counselling but are not sufficient in themselves since doctors wishing to engage in therapeutic discussions of a psychological nature must also have a grounding in interpersonal dynamics. The question arises therefore of whether departments of psychiatry should devote a proportion of their (usually) very large number of contact hours to the acquisition and assessment of psychotherapeutic skills or whether such teaching should be reserved for postgraduate doctors with a special interest in this area.
Not surprisingly, our survey raises more questions than it can answer. We trust that our observations stimulate discussion about the goals of undergraduate teaching in psychiatry and the best methods to achieve these aims.
Footnotes
Acknowledgements
This study could not have been compléted without the time, patience and good humour of heads of departments and class coordinators in the following universities: Adelaide, Auckland, Flinders, Melbourne, Monash, Newcastle, New South Wales, Otago, Queensland, Sydney, Tasmania and Western Australia. We thank Professor Rob Kydd, Dr Ken Kirkby and Dr Marina Vamos for comments on a draft questionnaire.