Fine-tuning Postgraduate Psychiatry Training in South Asia

Postgraduate training in the specialty of psychiatry has been in place in the South Asian region for decades. The training has produced a cadre of competent psychiatrists who have served their countries, as well as many parts of the world to which they have migrated. Many of them have gone on to be global leaders, innovators, and astute clinicians.

This withstanding, as with all specialties in medicine, is that the post-graduate curriculum in psychiatry needs constant review to ensure that it is “fit for purpose.” It meets the needs of an advancing world with bigger and more challenging issues, especially in the mental health realm. ¹

Background

Here, we will focus on the current training in the South Asian region. Apart from Afghanistan, Bhutan, and the Maldives, Bangladesh, India, Nepal, Pakistan, and Sri Lanka have their postgraduate training programs. The training programs are based on a traditional immersed-in-course training that draws heavily on the elucidation of psychopathology leading to arriving at an ICD10 or 11/DSM 5 diagnosis while also integrating evidence-based treatment approaches. The training leads to an MD in Psychiatry and, in some cases, an MPhil, which enables a person, depending on certain country-specific or state-specific criteria, to go on to independent practice as a Consultant Psychiatrist both in the public and private sector. The training ranges from three to five years, often including a research dissertation.

While empirically meeting the needs of the specialty, we must recognize the ever-changing realities, some global and others local, that demand further refining of the training curricula. ² In this context, focusing on Competency-Based Medical Education (CBME) may be prudent. ³ CBME identifies core competencies that need to be developed for the psychiatrist to meet the varying needs of the people and communities they serve, including cultural competency.^4,5

Training Needs

The South Asian psychiatrist must be more than a competent clinician. In the context of a dearth of mental health services and personnel, not to mention limited funding, the training must factor in the scarce resources and the overwhelming need for care that has to be met by the psychiatrist. ⁶ The psychiatrist has to be equipped with a range of knowledge, skills, and attitudes that exceed the competencies of a psychiatrist in a high-income country who may work in the narrow confines of a niche service.

Broadly, four overarching domains of competency will need attention. They are: (a) clinical acumen, (b) training as a teacher and educationist, (c) leadership for service development, and (d) locally relevant and applicable research.

Clinical Acumen

The South Asian psychiatrist must be firmly grounded in the understanding of local culture and beliefs to be able to interpret the unique presentations. Aligning the contextual pathology to modern scientific understanding of mental illness and communicating appropriately with patients and families is a skill that needs practice, empathy, and understanding of people from different experiences to that of the practitioner. ⁷ Furthermore, all psychiatrists will need reasonable competency in assessing and treating all the subspecialties as there are. However, a few sub-specialists need help to meet the needs of the large populations they serve.

Teacher and Educator

To meet the mammoth demand for services, much of mental health and psychiatric service provision will have to be at the primary care level. There has to be considerable task sharing and task shifting to categories of staff who may have to deliver many of the interventions. ⁸ This needs a sound teacher and educator who is able to train other doctors, nurses, medical students, psychologists, counselors, occupational therapists, and social workers in the many aspects of mental health to which they can specifically contribute. ⁹ The psychiatrist also has to play the role of an expert and communicate with not just other professionals but also with the media and the public. The huge treatment gap in low and middle-income countries can only be bridged by the psychiatrist taking on a pivotal role in improving the public understanding of mental illness and its treatment and minimizing the stigma in seeking appropriate care. ⁹

Leadership

There is a crying need for leadership in psychiatry. Most medical administrators in South Asia give psychiatry second-class importance. It is less fashionable than most medical specialties and, therefore, receives little attention or resources. Psychiatrists, therefore, have to be determined advocates, representing the specialty at every opportunity, emphasizing the huge need, and bravely weathering the negativity and stigma that is often directed at psychiatric personnel. This is an aspect of training that is easier to impart if the trainee is mentored by a senior psychiatrist and is exposed to real-life situations. In the training curricula in Sri Lanka, for instance, there is a period of senior registrarship, a minimum of one year after the MD, where the candidate works as a shadow consultant, often representing the unit at hospital meetings and other fora. Assessing these competencies is often a challenge, but it nevertheless needs cognizance. ¹⁰

Research Training

A solid grounding in research methodology is vital for two reasons. First, to interpret and critically appraise the flood of research evidence from high-income countries, which may sometimes be inapplicable or cost-effective for the region. ¹¹ Secondly, to spend the limited time and resources available on meaningful research that will benefit the local socio-economic milieu and could be scaled up for large populations to have a lasting impact. ¹²

Reflection and Altruism

To add to the above, a lifelong dedication to develop the specialty amidst the threat of “burnout.” The overwhelming demands placed on the psychiatrist can often be enormously daunting. The training will promote self-awareness, which helps the individual balance their priorities to live a contented and immensely satisfying life in the service of humanity. The training will have to inculcate then a commitment to reflective practice and spiritual altruism, qualities that extend beyond any formal curricula. ¹³

Conclusion

The time is ripe to join hands to develop a competency-based postgraduate psychiatry training curriculum that addresses the above needs in our region.

Furthermore, the training should produce ethical and compassionate doctors, not governed by just a duty of care but a true mission to improve the mental health of individuals, families, and communities.