This paper outlines the changes in specialist training that are occurring and also how postgraduate teaching is currently delivered in psychiatry. There is a review of the different ways that teaching can be delivered. Suggestions are then made as to how teaching can be organised in the specialist training programme in psychiatry.
Background
Under Modernising Medical Careers (MMC) trainee doctors are now appointed to structured training programmes. Training is delivered in line with the Royal College published curriculum approved by the Postgraduate Medical Education and Training Board (PMETB) (Reference BrownBrown, 2005). This will result in training continuing to move from the apprentice model toward a more systematic approach. As a consequence a variety of teaching and learning methods will need to be deployed with the focus on day-to-day clinical working.
As part of these changes a new format for the Membership of the Royal College of Psychiatrists (MRCPsych) examination is to be introduced in Spring 2008. This will integrate national assessment with local assessment and appraisal in line with the training changes implemented following the introduction of MMC.
Current teaching
Trainees are currently expected to attend a weekly local teaching programme (often comprising a case conference and/or journal club) and a local accredited MRCPsych course. The Basic Training Handbook contains the only guidance on the running of MRCPsych courses:
All trainees must attend a recognised MRCPsych course comprising a systematic course of lectures and/or seminars covering basic sciences and clinical subjects relating to basic specialist training and the published MRCPsych curriculum.
For current specialist registrars (SpRs), separate regular academic meetings are generally organised within each specialty. Within the West Midlands region there are two MRCPsych courses structured along similar lines. The Birmingham MRCPsych course uses the lecture format to deliver most of the teaching; this is partly a matter of being pragmatic as 100 trainees attend the course from the three training schemes in the southern half of the West Midlands region. The course is designed and structured using the existing College syllabus and knowledge of the examination requirements. It is divided into two 6-month semesters for the part 1 course and three such semesters for part 2.
What are the issues for the course?
Attendance
Although mandatory, attendance at the courses has sometimes been below expectations. Over the last 2 years great efforts have been made to increase attendance: by giving rapid feedback about non-attendance to both trainees and tutors; by providing attendance certificates; by monitoring and altering course content in line with trainee feedback and changing need; and by greatly improving the ‘no show rate’ for lecturers. Attendance has sometimes been impeded by the introduction of the European Working Time Directive. Recent rates of attendance are in the region of 75% for the part 1 course and 65% for the part 2 course.
Feedback from trainees
Consistently the feedback from the trainees both from questionnaire surveys and from nominal groups (Reference Delbecq, Van de Ven and GustafsonDelbecq et al, 1975) has been: ‘To make the course more examination focused’ and ‘to make the lectures more interactive’.
Many of these issues have been addressed, with regular examination revision lectures and courses and the publication of all lectures on the internet. Recently a workshop was run for all lecturers on the MRCPsych course highlighting the trainees’ feedback and discussing ways to make the teaching more interactive.
Teaching methods
Lectures are an effective method of teaching enabling large amounts of information to be transmitted (Reference Brown and ManogueBrown & Manogue, 2001). However, the attention of learners during a lecture tails off quickly and by 20 minutes has reduced significantly (Reference BiggsBiggs, 1999; Reference BlighBligh, 2000). Various ways to increase the efficacy of lectures and maintain learners’ interest have been described (Reference CantillonCantillon, 2003).
Small group teaching (Reference WaltonWalton, 1997) is more likely to promote understanding and an ability to synthesise information. It is characterised by student participation and interaction and there is some evidence that it is a more effective method of education than traditional methods (Reference Springer, Stanne and DonovanSpringer et al, 1997). Small group teaching is not without its problems and must be actively managed (Reference JaquesJaques, 2003); although individual feedback is facilitated, specific techniques to deal with ‘problematic’ learners may be required. Feedback from service users and carers involved with the Birmingham course has also indicated a preference for interactive small group teaching.
One form of small group teaching is problem-based learning which reverses the usual approach to teaching by beginning with a clinical scenario or problem, which through its solution encourages the learners to consider broader concepts. It improves deep learning by integrating new knowledge with existing principles, as well as promoting self-directedness and collaboration with peers (Reference Davis and HardenDavis & Harden, 1999; Reference WoodWood, 2003). Dolmans et al (Reference Dolmans, De Grave and Wolfhagen2005) describe three essential characteristics of problem-based learning: patient problems act as a stimulus for learning; teachers are facilitators who stimulate students towards self-directed learning; and the small group interactions act as a stimulus for learning. Trainees must find relevant information for themselves from written sources and experts, and talk about this in a group with a facilitator.
A proposal to change the MRCPsych course
Over the last 12 months the Birmingham and Solihull Mental Health Trust has been running weekly small groups for Foundation Year (FY) 1 and FY2 trainees in psychiatry. Using problem-based learning and other small group techniques they have enabled curriculum coverage (indeed they have gone further than the published curriculum aims of the Foundation Programme) that was popular with the trainees, achieving an attendance rate of more than 90% consistently.
In order to adapt to the training needs of the year 1 Specialty Trainees and Fixed Term Specialty Training Appointments implemented in August 2007, the Birmingham course will need to change. This course structure will be replicated in the MRCPsych course in the north of the region (based at Keele University). The course content will be determined by the new curriculum and the structure will be modular with a focus on clinical conditions, areas of knowledge, and development of clinical skills and professionalism. The component parts will include the following:
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• A core teaching programme to be held fortnightly/monthly for all specialty training year 1 (ST1) trainees consisting of lectures and seminars led by experts as well as patients and carers in the given field of study. This will enable trainees from across the region to meet with one another and enable the delivery of other specific sessions including those shared with other disciplines (e.g. psychologists). There will also be discussion of the topics to be covered in the following month in the weekly small group sessions.
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• Weekly local small group teaching. This will take place in local units. The content of the small group sessions will complement the core teaching and will follow the pattern of our foundation year teaching, with the opportunity for additional problem-based learning teaching. The content of the small group teaching will be determined centrally so that all ST1 trainees will follow the same programme.
Box 1. Sample module on schizophrenia and delusional disorders
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• Week1: Core teaching programme for allregional ST1 trainees
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• Lectures:
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• Morning
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• Psychopathology and clinical features of schizophrenia
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• Epidemiology, aetiology and prognosis
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• Treatment and management
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• Afternoon
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• Service user perspective
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• Carer perceptions
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• Seminar on multidisciplinary working including voluntary agencies
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• Week 2: Local small group teaching
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• Problem-based learning:
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• Treatment resistant schizophrenia
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• Learning points e.g. reconfirm diagnosis, recognise perpetuating factors, evidence-based treatments for resistant schizophrenia
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• Week 3: Local small group teaching
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• Case presentation:
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• A difficult case to manage
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• Journal club:
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• Critical appraisal on use of cognitive-behavioural therapy for symptoms of schizophrenia
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• Week 4: Local small group teaching
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• Small group teaching:
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• Observed patient/simulated patient interviews
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Box 1 illustrates how such a module might work. Accompanying the teaching programme there will be course and modular study guides. These will highlight the ground to be covered including: competency domains; methods of learning; useful learning experiences; multiple choice questions; and reading at core and more advanced levels. Lecture and seminar notes will continue to be made available on a course website and the possibility of producing MP3 (MPEG-1 audio player 3) downloads for lectures is being explored. Such a model has the advantage of using a variety of teaching methods including didactic teaching. One existing source of teachers is the college tutors, a group of consultants with interest and experience in education; co-opting them to act as tutors on the new course has the advantage of integrating them more thoroughly into the structure of the new regional schools of psychiatry. In the West Midlands, the School of Psychiatry has obtained the broad agreement of college tutors that each should have some responsibility for a particular ST year as well as geographical responsibility for trainees in their trust.
Box 2. Example of problem-based learning
Theme: Assessment of a 34-year-old man with schizophrenia in the local accident and emergency department.
Aim: Identify and manage a case of treatment-resistant schizophrenia.
Learning objectives:
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• list the key symptoms of schizophrenia
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• prioritise relevant differential diagnoses
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• identify relevant aetiological factors
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• prioritise treatment options
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• demonstrate knowledge of legal frameworks for compulsory treatment.
Example questions:
What symptoms or signs support each differential diagnosis, and what other symptoms would you look for? What legal frameworks may be of use in the immediate and longer term?
References: Two to three basic references will be provided. Trainees will be given tuition on literature searching to help identifying alternate resources.
Timetable:
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• Week one - Scenario given out then group discussion with facilitator
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• Week two - Trainees work individually or in groups to explore tasks
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• Week three - Trainees meet local tutor for any guidance and help
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• Week four - Presentation of findings and group discussion
A more detailed plan is available from the authors
Once the teaching has been set up for the ST1 trainees, this cohort will continue to receive their teaching in this new format as they become ST2 trainees and subsequently ST3 trainees. Teaching for the ST4-6 grades will continue to be organised in terms of specialty.
The introduction of different methods of teaching requires careful planning. For instance in implementing problem-based learning, difficulties that may arise include: those to do with the construction of the case scenarios; the degree to which the facilitator directs the group; and those of dysfunctional group dynamics (Reference Dolmans, De Grave and WolfhagenDolmans et al, 2005). Box 2 shows an example of a problem-based learning case. In order to ensure that self-directed learning takes place and trainees are able to learn independently, the role of the facilitator in problem-based learning is crucial (Reference Mclean and Van WykMcLean & Van Wyk, 2006). An essential component of the new course is a training programme for facilitators (Reference Murray and Savin-BadenMurray & Savin-Baden, 2000) which is currently being constructed.
Conclusion
The changes in medical training resulting from MMC and the introduction of a new style of MRCPsych examination provide the opportunity to have a fresh look at the best way to provide teaching for psychiatric trainees. We have outlined a structure that should meet the learning needs of trainees. The challenge will be to ensure that the teaching is delivered in a consistent manner throughout the region.
Declaration of interest
None.
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