Developing clinical skills in psychiatry

The Royal College of Psychiatrists’ curriculum recommendations, informed by the General Medical Council's (GMC) ‘Outcomes for Graduates’,¹⁵ states that an important aim of undergraduate psychiatry education is for ‘students to develop the necessary skills to apply [professional] knowledge in clinical situations’.¹⁶

Clinical placements form the bulk of students’ experience in psychiatry in the UK,^{Reference Karim, Edwards, Dogra, Anderson, Davies and Lindsay17} offering opportunities for experiential learning and participation in authentic clinical environments.^{Reference Morris, Swanwick, Forrest and O'Brien18} However, 87.5% of schools were forced to decrease the proportion of time that students spent on clinical placement. Even when clinical placements were possible, service changes and social distancing requirements changed the nature of their learning opportunities. Without these experiences, students may have difficulty in understanding how to apply their professional knowledge in clinical contexts. Indeed, the Medical Schools Council notes that ‘it is not possible for students to meet the requirements set out in the GMC's Outcomes for Graduates without undertaking clinical placements’.¹⁹

During the pandemic, schools continued to provide clinical skills, role-play or simulation teaching, with 45.8% delivering these fully online. Although online skills teaching can alleviate students’ concerns about reduced patient contact,^{Reference Hickland, Gosney and Hare20} learners feel less prepared to use skills learnt in practice.^{Reference Carroll, Mooney and Horowitz21} In a survey of UK medical students in May 2020, three-quarters felt that online teaching had not successfully replaced the clinical teaching that they received from direct patient contact.^{Reference Dost, Hossain, Shehab, Abdelwahed and Al-Nusair22}

A total of 95.8% of schools used teleconferencing on clinical placements, which, though useful, has limitations. For instance, the court judgment on remote Mental Health Act assessments noted that ‘a psychiatric assessment may often depend on much more than simply listening to what the patient says … [and] may involve a multi-sensory assessment’.²³ In consultations by teleconferencing, clinicians face difficulties in reading non-verbal communication, using silence and incorporating physical examination.^{Reference Chen, Chung, Young, Tuttle, Collins and Darghouth24} Without the opportunity to see clinicians demonstrating these skills and to practise these skills themselves, students are left with an experience that translates poorly to the face-to-face situations they will encounter in the future. Moreover, clinicians cannot model some skills that are important in face-to-face work, such as preparing consultation rooms or judging physical distances between patient and clinician. Nevertheless, telepsychiatry is likely to be used more widely in the future.^{Reference Shore, Schneck and Mishkind25} Early training can foster specific skills, such as conducting mental state examinations by telephone.^{Reference Ramkisson, Dave, Abraham, Pillai, Moir and Matheiken26} These should supplement, but not supplant, the acquisition of skills for face-to-face interactions.

The shift away from workplace learning was accompanied by an increase in self-directed learning and the use of online tasks. Self-directed learning prepares students for lifelong learning, and online tasks provide the opportunity to develop a broader knowledge base. However, some schools decreased teaching in the subspecialties, with psychiatry of intellectual disabilities, forensic psychiatry and medical psychotherapy most affected. This means that the only available opportunities to learn skills in these subspecialties may have been lost; for example, learning to communicate with people with intellectual disabilities and understanding unconscious aspects of the doctor–patient relationship.

The fact that assessments have continued with no change in standards during the pandemic is reassuring. Indeed, the greater emphasis on formative assessments and developmental conversations with individual clinicians may provide more opportunities for students to receive feedback.

Attitudes toward mental illness

Reductions in time spent in clinical placements mean that students get less contact with people with psychiatric conditions, which is so important in dispelling stigma toward mental illness.^{Reference Lien, Lin, Lien, Tsai, Wu and Li27} The relative shift away from placements in community teams toward in-patient wards during the pandemic may also have unintended consequences; in a meta-analysis conducted before the pandemic, in-patient placements had less effect in challenging stigmatising attitudes than community or mixed placements.^{Reference Petkari, Masedo Gutiérrez, Xavier and Moreno Küstner28}

On the other hand, the greater emphasis placed on the mental well-being of students^{Reference Zhai and Du29} and healthcare staff^{Reference Tracy, Tarn, Eldridge, Cooke, Calder and Greenberg30} during the pandemic may encourage students to pay attention to their own health and well-being, and raise their awareness of the importance of mental health. Psychiatry teachers are particularly well-equipped, with expertise in both mental health and undergraduate education, to support students.

Recruitment into psychiatry

Experiences during clinical placements affect career choices, with just over half of students reporting that they were more inclined to choose a career in psychiatry following their placement.^{Reference Halder and Mulliez31} Placement factors that encourage students to choose psychiatry include perceived clinical responsibility and influence of teachers as role models.^{Reference Farooq, Lydall, Malik, Ndetai and Bhugra32,Reference Choudry and Farooq33} Although an international survey found no relationship between placement length and choosing psychiatry,^{Reference Farooq, Lydall, Malik, Ndetai and Bhugra32} a placement should be sufficiently long for students to get involved in the team and follow patients’ progress.^{Reference Appleton, Singh, Eady and Buszewicz34} Shifting away from workplace learning reduces such opportunities and may affect recruitment into psychiatry.

The pandemic has also limited opportunities (e.g. through lack of availability of electives) for fully exploring different subspecialties.^{Reference Byrnes, Civantos, Go, McWilliams and Rajasekaran35} Tasters, where students spend short periods of time experiencing subspecialties outside of their main clinical placement, demonstrate to students the breadth of opportunities that a career in psychiatry entails.³⁶ Social distancing measures limit access to tasters. Despite these limitations, most education leads agreed that the pandemic had raised the profile of psychiatry among medical students. Increased awareness of reflective practice and a renewed focus on student well-being may have contributed to this. Whether this will translate into more positive attitudes toward psychiatry from other specialties is unclear.^{Reference Ajaz, David, Brown, Smuk and Korszun37}

A call to action in a time of change

The pandemic has been a catalyst for spurring innovations in medical education.^{Reference Gibbs38} Even after the pandemic, there will be changes to psychiatry teaching in the majority of schools. Most education leads are optimistic that the pandemic will change psychiatry education for the better. Students have responded positively to the adaptations to teaching and, mirroring the changes predicted by our respondents, want to continue with online lectures and increased access to online resources in the future.^{Reference Coffey, MacDonald, Shahrvini, Baxter and Lander39} It remains to be seen whether reactive adaptations implemented during the pandemic will be sustainable, and help to manage another impending challenge: the surge in student numbers resulting from the government temporarily lifting the cap on medical school places.^{Reference Rimmer40}

One year on from the first national lockdown, the course of the pandemic remains uncertain. But what is becoming more certain is the profound impact that the pandemic has had on the way we teach psychiatry. This is most marked in the reduction of clinical placements, which may affect the attainment of key competencies relevant to practice in all branches of the profession, exposure to clinical role models and the challenging of stigmatising attitudes to mental illness and psychiatry. Reduction in clinical placement may also pose a threat to future recruitment into psychiatry at a time when there will be an even greater need for psychiatric skills, to manage increased demand following the pandemic.^{41,Reference Carr, Steeg, Webb and Kapur42}

This is the time for all of us in psychiatry to unite and rise to the challenges that lie ahead. We call upon individual clinicians, NHS trusts and medical and foundation schools to work closely together and with students, to give this generation the training that they need to best care for patients in the post-pandemic landscape.

Individual clinicians can offer so much to maximise the quality of learning during shortened placements. They can offer opportunities for students to participate fully in the care of patients and foster experiential learning. Trusts continue to receive payment for educating students, even with reduced time spent in clinical settings, and can ensure a more equitable distribution of finances to front-line educators.^{Reference O'Brien and Korszun43} Teaching during the pandemic has required considerable planning and effort from education leads, yet in our survey, few reported receiving additional funding or resources.

Medical schools should incorporate opportunities, wherever possible, for students to meet psychiatrists and experts by experience, to implement training on stigma and support the activities of student-led psychiatry societies.^{Reference Pandian, Mohamedali, Chapman, Vinchenzo, Ahmed and Mulliez44} Lost learning opportunities should be prioritised for inclusion in online teaching programmes both during and beyond medical school. Foundation schools should similarly increase postgraduate psychiatry teaching and the number of posts in psychiatry. Greater collaboration between foundation programme leads and undergraduate educators is important to replace what has been lost during the pandemic.

Undergraduate psychiatry teaching in the UK has undergone extensive adaptations in response to COVID-19. Educators have done a remarkable job to maintain the integrity of teaching in the face of considerable adversity. Lessons learnt during the pandemic will shape teaching in the future. As we start our journey into the post-pandemic world, we hope that readers will heed our call to action. We must not let the pandemic set back decades of progress in the care of people with mental illness.

Strengths and limitations

To our knowledge, this is the first nationwide survey of adaptations in undergraduate psychiatry teaching in any country. There was a good response rate of 72.7%, with responses from all four nations of the UK. By asking education leads about specific areas of adaptations, we may not have captured all the adaptations made at individual schools. Similarly, there was variable completion of open questions and depth in respondents’ descriptions of adaptations. As a survey of education leads, we have not explored first-hand the views of students and other clinicians on the impact of adaptations. Lastly, the survey offers a snapshot of adaptations at a particular moment in time, and does not capture longitudinal changes in response to the course of the pandemic.