Comment

The paper by O'Connor, Clarke and Presnell raises a number of interesting questions about the present practice of psychiatry teaching in Australasia. The details of their findings should stimulate debate in all teaching departments and raise a number of wider concerns for the profession as a whole. Whatever it is that we are doing, something is wrong. For 20 years now, observers have been commenting on the grinding down during Medical School of bright, energetic, young people. More recently, recruitment into psychiatry has gone into a serious decline across Australasia. The reasons for this are wider than curricular issues alone, but they may play a part.

Each generation of medical teachers, having survived their own medical training, appears to emerge with a conviction that they can crystallise the essence of medical training in a new and more relevant manner and make all plain to succeeding generations. These endeavours are pursued with dedication, polemic and not a little pomp. It is unsurprising then, given this level of personal investment, that a profession that so values the scientific method uses little of it in evaluating such changes. This is particularly highlighted in the present study by the difficulty in describing the nature of what was being taught, let alone the manner of teaching in clinical settings and whether this was effective.

The tide of fashion in medical education in general, and psychiatric education as part of this, ebbs and flows with the generations. We have been taught to see the emphasis on scientific method promoted by Flexner as a watershed. In this, Flexner was trying to promote a more informed approach to the understanding of the underlying principles of medicine and thus produce more thoughtful practitioners. This was hugely influential and has been adopted throughout the Western influenced world. We now have the ascendancy of problem-based learning: to ensure that students integrate basic sciences with clinical observations in a manner that leads to a more thoughtful approach to medicine. Assessments have moved from the apprentice style rites of passage of the Middle Ages, through a final summative examination marathon (‘finals') earlier this century, and then back to continuous assessment in the late 1960s. More recently, the demand that students negotiate rather a lot of both of these approaches seeks to cover all bases. The learning process has moved from the highly controlled apprentice of yore to Richard Gordon's uncontrolled medical dilettante (one might unkindly suggest ‘self directed’ in modern terms) and back again, with no clear resolution of what is most effective. There would seem to be great opportunity for controlled comparisons. However, while many are willing to opine on what represents a competent graduating doctor or specialist, few are yet game to determine the parameters predicting a good doctor 10 or 20 years later, which is, perhaps, the real question. What research there is tends to focus on the reliability of examinations or descriptive outcomes. McMaster, doyen of problem-based learning, produces relatively more general practitioners and academics than traditional medical schools. Is this a good outcome or just a different one?

The range of course content has been considered excessive for at least a century; however, selecting what is essential is by no means easy. A key conflict for all specialist disciplines is whether to focus on the presumed future needs of the generalist, or to offer an insight into the particular challenges and attractions of specialty practice.

Many curricula aim to educate students in the assessment and management of common and important disorders. However, what is common and what is important will vary depending on the long-term work setting. Until recently, many would say that it was the common disorders encountered in general practice, depression, anxiety and alcohol disorders, that should be the core of undergraduate teaching. With the establishment of general practice as a specialty, we need to reconsider whether it is appropriate that our teaching should be, de facto, a last opportunity to offer education in mental illness to future general practitioners, with little consideration of the needs of other disciplines. Even so, changes in the delivery of mental health services mean that the long-term care of those affected by psychoses is more relevant to general practitioners than it once was.

The authors bemoan the lack of experience gained by students in various specific aspects of mental illness. While I have sympathy with many of the points raised, such training requires time to ensure that students are able to apply their learning and enhance their skills in a clinical setting. We are beginning to face real challenges in the provision of clinical training within existing public services. One issue is that there are fewer patients in inpatient facilities than there once were, and those who remain are the most severely ill, many too ill to contribute to medical student teaching in the way that was previously the norm. Another issue arises out of the success of the consumer movement. This has had a powerful (and, of course, welcome) effect in empowering patients’ self-determination. Many consumers now feel freer to decline to participate in such teaching. Asimilar situation has arisen for our colleagues in obstetrics and gynaecology, where many women are now able to express their reluctance to be examined by a series of medical students. The obstetricians and gynaecologists now use models so students are better prepared when they do examine real patients. It is perhaps time that we gave serious consideration to how we are to adapt teaching in psychiatry, whether through interviewing simulated or virtual patients, or in other ways. Most medical schools have yet to build formal relationships with consumer groups in the way that will be essential to addressing such matters. Furthermore, as our health systems change their focus from publicly funded institutional provision to other models, we need to adapt our approaches and build relationships with all providers.

In terms of content of learning, the development of clinical practice guidelines and pathways may allow more rapid teaching of the principles of care. This would allow more time to explore those areas that are often neglected. And, if we really believe our principles of problem-based learning, we don't have to make sure that all students have experienced all types of practice, provided the key skills are assimilated.

We are prone to disparage the efforts of our predecessors, sometimes with little regard for what they achieved. I was recently perusing Dr Hooper's Physician's Vade Mecum of 1851 (the Oxford Handbook of Clinical Medicine of the day, perhaps). I was intrigued to find that the first chapter consists of a discussion of temperament (albeit in traditional Hippocratic terms) and its impact on the presentation of medical disorder. When its modern successors give similar prominence to such matters again, we will indeed have made progress.