Modernising Medical Careers (http://www.mmc.nhs.uk/pages/home) and the Postgraduate Medical Education and Training Board (PMETB; http://www.pmetb.org.uk) have become part of everyday vocabulary with regard to the training of medical professionals in the UK. These initiatives are bringing about changes in training methods and the educational system, but where is the evidence showing which components of training work and which do not?
There is growing emphasis on defining an evidence base for medical education and practice (Reference Harsden, Grant and BuckleyHarsden et al, 1999). More than 30 years ago, Reference BrookBrook (1974) reported a survey of training experiences of recently appointed psychiatric consultants in the UK. He found that a number of important aspects of training had been experienced by only a minority of trainees and that for the majority clinical experience had been poorly supervised and taught. His findings showed major deficiencies in certain areas of training, notably psychogeriatrics (old age psychiatry); medico-legal work; experience with ward consultations; dealing with psychiatric emergencies; and the specialties of mental handicap (intellectual disability), child psychiatry and forensic psychiatry. He recommended that academic units in universities and medical schools be strengthened.
We decided to undertake a systematic review of the literature to examine the evidence base for current education and training initiatives in psychiatry in the UK. Our methods and more detailed results appear as a data supplement to the online version of this editorial. Here, we discuss the implications of our findings.
The current evidence
Most studies on postgraduate psychiatric training and outcomes have been conducted in the USA, Canada and Australia. We found only 24 papers from 1996 to the present that focused on the UK, 10 of which were research publications evaluating the quality of training (Table 1, online data supplement) and 14 were editorials or narrations about psychiatric training. We were unable to identify any randomised controlled or before–after studies. There were no papers on the reliability and validity of the various methods used for postgraduate training in psychiatry, nor were there any recent studies of the usefulness of training methods in improving the competence or skills of trainees. Of the papers with a research design (Table 1, data supplement), only two were on psychotherapy training, and one each on forensic psychiatry training, logbooks, supervision, ethnicity, special skills (flexible training) and satisfaction with training. Overall, the quality of trainees was reported to be good and ‘flexible trainees’ were reported to be better than average. Eight studies were cross-sectional, one retrospective and one prospective. The themes of the studies were variable, and it was therefore difficult to summarise their findings.
Discussion
At a time when most clinical practice and guidelines are evidence based and the emphasis is on training, it is surprising to find a lack of evidence supporting methods of postgraduate psychiatric training. There are no systematic reviews, no controlled studies, no randomised studies and no studies on the reliability or validity of training methods.
It may be difficult to predict from research studies on methods and programmes of training how these reflect the competence and skills of the trainees, but the attempt must be made in psychiatry as it has been in other fields of medicine. Randomised comparative studies have been conducted in dermatology (Reference Ochsendorf, Boehncke and BoerOchsendorf et al, 2004) and on the use and success of medical journal clubs (Reference Linzer, Brown and FrazierLinzer et al, 1988), and there are systematic reviews of postgraduate medical teaching (Reference Coomarasamy, Taylor and KhanCoomarasamy et al, 2003) and critical appraisal skills (Reference Taylor, Reeves and EwingsTaylor et al, 2000).
Training in psychiatry is based on paradigms that are largely historical. The reliability, validity and generalisability of the methods used have scarcely been addressed. Many aspects of psychiatric training are as relevant to UK trainees as they are to those in other Western countries. These include the quality of supervision, training in psychiatric sub-specialties, quality assurance in training, logbooks, research experience and part-time flexible training (Reference Day, Grimmer and LloydDay et al, 2002). However, training methods in the UK are at variance with those in the USA, Canada and Australia. It is clear that we need well-designed systematic studies of current training programmes and teaching methods in the UK, to provide an evidence base justifying these differences. In view of the changes in psychiatric training already set in motion by Modernising Medical Careers and PMETB, further evaluative research is indicated as a matter of urgency.
Declaration of interest
D.B. is Dean of the Royal College of Psychiatrists.
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