Patient-centred psychiatry Training and assessment : the way forward {

Patient-centred psychiatry depends upon delivering care which is patient focused. Patient-centred care is defined as A key advantage in psychiatry compared with many other medical specialties has been its focus on teamwork for managing patients. Much of the content of Stewart’s definition has

Patient-centred psychiatry depends upon delivering care which is patient focused.Patient-centred care is defined as (Care) which explores the Patients'reasons for their visit, their concerns and need for information, seeks an integrated understanding of the patient's world i.e. their whole person, emotional needs and life issues and finds common ground on what the problem is and mutually agrees on management, enhances prevention and health promotion and enhances the continuing relationship between the patient and the doctor (Stewart, 2001) A key advantage in psychiatry compared with many other medical specialties has been its focus on teamwork for managing patients.Much of the content of Stewart's definition has already been happening in psychiatry, although this may have been patchy.
The six interactive components of the patientcentred process are listed in Box 1.

Characteristics of a good psychiatrist
The core attributes listed in Good Psychiatric Practice (Royal College of Psychiatrists, 2004) are: clinical competence, being a good communicator and listener, being sensitive to gender, ethnicity and culture, commitment to equality and working with diversity, having a basic understanding of group dynamics, being able to facilitate a positive atmosphere within a team, ability to be decisive, ability to appraise staff, basic understanding of operational management, understanding and acknowledging the role and status of vulnerable patients, bringing empathy, encouragement and hope to patients and carers, critical self awareness of emotional responses to clinical situations, being aware of potentially destructive influence in power relationships and acknowledging situations where there is potential for bullying.
A comparison between the components of Box 1 and the attributes of a good psychiatrist indicates a tremendous area of overlap in the qualities of an individual as well as the characteristics of a service which will be acceptable to patients and their carers.
As the consultant of the future will have to have a range of competencies in clinical management, teaching, research and other areas, the training of such individuals will have to take on board a number of parameters which will include peer group based learning, learning across disciplines and teams, and continuing professional development.

Current developments in postgraduate medical education
A number of major changes are taking place in postgraduate medical education.In fact, the scale of changes is almost certainly unprecedented, and it is likely that they will need to be put into practice fairly rapidly.This is because they will be required or affected by legislation that will come into force in 2005.
Five main driving forces are: 1.

Modular assessments
Modular assessments could be appropriate in the following areas: child and adolescent psychiatry; learning difficulty; forensic psychiatry; psychiatry of old age; and substance abuse.It could be that a proportion of the marks for the MRCPsych II should come from modular and place of work assessments (PWA).Modular assessments could include theoretical examinations conducted locally, but with standards monitored and maintained centrally.These might be held perhaps once a year, but the resource implications for the examinations department could be immense.

Workplace-based assessments
It seems likely that the PMETB will place considerable importance on workplace-based assessment as they have constituted a special subcommittee for this specific purpose.
There are several options under consideration for workplace-based assessments: 1. Assessing the trainee's letters to the GP and referral letters to other agencies.2. Observing the trainee interviewing a patient.3. Observing the trainee presenting cases to the team members/consultant on the telephone.

Observing the trainee giving information to carers.
There is also a well-developed workplace-based assessment method called mini-CEx that is likely to be appropriate for this purpose.Box 3. The PMETB 9 governing principles for assessment 1 The assessment system must be fit for a range of purposes.
2 The content of the assessment (sample of knowledge, skills and attitudes) will be based on curricula for postgraduate training which are referenced to all the areas of Good Psychiatric Practice.
3 The methods used within the programme will be selected in light of the purpose and content of that component of the assessment framework.

Postgraduate Medical Education andTraining Board principles of assessment and standards
The PMETB has repeatedly emphasised that assessments must be based, not on the factual recall of knowledge, but on competency (what the doctor can do) and performance (what the doctor does do).This is why workplace-based assessment is likely to be so important and the emphasis on traditional written examinations will decrease.
The PMETB has set out 9 governing principles for assessment -these are illustrated in Box 3.

Training models
In view of the two foundation years (Modernising Medical Careers) it is our intention that all trainees have a minimum 5-year training in psychiatry.The psychiatry training in foundation years will not be counted towards postgraduate training, nor are they expected to be in any other specialty.
The foundation year 2 and its contents and any assessment at the end of it is not dealt with in this paper (see Brown & Bhugra, 2005a).
Entry criteria for postgraduate training in psychiatry will remain the same.
We need to consider the possibility of MRCPsych Part I as a suitable screen for entry into the speciality and for sitting the examination within 6-9 months of starting the training.The assessments will have to be competencybased. Exit

Sub-specialist training
After the CCT, trainees could choose to super-specialise in various areas.These could include academic psychiatry, for example, or a combination of more than one superspeciality such as forensic psychotherapy.
Some guidelines for super-specialist training are listed below.
. Training and need-assessment to be modular.
. A national workforce coordination will be essential and the Royal College of Psychiatrists will take the lead.
. Selection after foundation year 2 will be competitive but in both models 5-year training will be the norm.
. Funding of posts will be through the deaneries.
. Curriculum and competencies will be referred to the SpecialistTraining Authority (initially) and to the PMETB.
. The assessments will be transparent and the Royal College of Psychiatrists will guarantee standard setting and quality assurance.
. Exit will be competency-based and a single CCT may be offered as suggested by PMETB.
. Flexible training will follow the same competencybased assessments.
Table 1 illustrates the roles and methods of learning.
Brown & Bhugra, 2005b)me Directive (EWTD) and Implementing the European WorkingTime Directive: Guidance from the Academy of Medical Royal Colleges (Academy of Medical RoyalColleges, 2004) (see alsoBrown & Bhugra, 2005b).5.The Royal College of Psychiatrists'commitment to involving patients and carers throughout specialist education in psychiatry.