Problem-based psychiatry in a new undergraduate medical curriculum

Traditional British undergraduate medical edu cation has evolved with the development of medicine as a profession. However, despite dramatic progress in the provision of health care, the medical curriculum has remained mostly unchanged until recently. Conventional medical courses rely on the teacher-centred didactic setting of a lecture theatre to transmit vast quantities of information. This one-way traffic of facts is divided initially into the preclinical basic sciences and later into the medical specialties, with relatively little horizon tal or vertical integration. Much of the assess ment of students relies on their reproducing information as accurately as possible. This traditional format has been widely criticised (Lowry. 1992). The information that a student is required to retain is excessive, of questionable relevance and soon becomes out of date. The assessment procedure involves rA©gurgitation of information in an anxiety-provoking setting that does not encourage more than a superficial understand ing. This form of assessment has become an end rather than a means to it. Thus, sight of the real purpose of medical education, that is, to enable the student to become a competent clinical practitioner and a lifelong learner, has been lost.


Problem-based psychiatry in a new undergraduate medical curriculum
Rajan Nathan, Trevor J. Gibbs and Kenneth C. M. Wilson Traditional British undergraduate medical edu cation has evolved with the development of medicine as a profession. However, despite dramatic progress in the provision of health care, the medical curriculum has remained mostly unchanged until recently. Conventional medical courses rely on the teacher-centred didactic setting of a lecture theatre to transmit vast quantities of information. This one-way traffic of facts is divided initially into the preclinical basic sciences and later into the medical specialties, with relatively little horizon tal or vertical integration. Much of the assess ment of students relies on their reproducing information as accurately as possible. This traditional format has been widely criticised (Lowry. 1992).
The information that a student is required to retain is excessive, of questionable relevance and soon becomes out of date. The assessment procedure involves rÃ©gurgitation of information in an anxiety-provoking setting that does not encourage more than a superficial understand ing. This form of assessment has become an end rather than a means to it. Thus, sight of the real purpose of medical education, that is, to enable the student to become a competent clinical practitioner and a lifelong learner, has been lost.

Background to change
In response to these criticisms, new and innov ative curricula have been designed, which rely on student-centred courses where subject matter is integrated and learning is problem based. Such curricula have been introduced in medical schools across the globe. McMaster University in particular has been a pioneer in this respect (Neufeld & Barrows, 1974). British medical schools have been less enthusiastic until recently. However, in 1991 the General Medical Council (CMC) strongly encouraged reform (General Medical Council, 1991). Subsequently many medical schools adopted piecemeal GMC recommendations. In October 1996. the Faculty of Medicine within the University of Liverpool took the bold step of introducing a completely new medical curriculum.

New medical curriculum at Liverpool
The course structure is based on a core curriculum plus options model with compre hensive integration of subject matter. The op tions are in the form of a series of special study modules. Objectives are defined in terms of skills and attitudes, as well as knowledge and under standing. Self-directed learning is emphasised in achieving these objectives through a problembased learning approach (Barrows & Tambly, 1980). The curriculum is divided into three phases. Phase 1 in the first year introduces students to the science and practice of medicine. Although medical (clinical and communication) skills are introduced in the first year, actual clinical experience begins in Phase 2 (years 2-4). Students progress from understanding normality (year 2), through recognition of abnormality (year 3), to diagnosing disease and planning patient management (year 4). Phase 3 in the final year involves apprentice-based clinical experience. Problem-based learning modules, each lasting one or two weeks, run throughout the first four years.

Problem-based learning
This review focuses on problem-based learning, which forms a major part of the curriculum reform at the Faculty of Medicine In the University of Liverpool. Problem-based learning is an educational approach, at the core of which is the presentation of a real clinical situation (Bligh, 1995). Typically, about five students and a facilitator meet regularly. Schmidt (1983) describes the steps involved. His description is of limited value in that it implies a rigid format that is not in keeping with the general philosophy of this approach. However his account illustrates the processes involved. The first step, which involves activation of prior knowledge, is clari fication of the terms used in the presentation. The problem then should be defined precisely. This allows analysis of the problem in terms of the underlying phenomena. By considering the questions raised, the group formulates learning objectives that are achieved through individual study using a variety of resources. When the group reconvenes, the new information is shared and applied to the original problem. This approach addresses many of the criticisms out lined above. Problem-based learning dispenses with the need for departmental segregation. By learning in the context of considering an actual clinical problem, the knowledge acquired is relevant to clinical practice. Problem-based learning produces conditions that have been shown by educational psychologists to facilitate learning (Engel, 1992). Such conditions include contextual learning, encoding specificity and the use of prior knowledge to organise and elaborate new information. In addition to these educa tional goals, problem-based learning encourages the development of further skills such as listen ing, summarising, collaborating, peer teaching and assessing.
Problem-based psychiatry As mentioned, one of the main learning environ ments in the new course at Liverpool is the problem-based learning group. The psychiatry module, which lasts four weeks, is in the second half of Phase 2. The module is based on the core curriculum for psychiatry, which follows CMC recommendations (General Medical Council, 1993). The development and design of such a core curriculum has been described elsewhere (e.g. Nasser, 1996: Working Party of the Educa tion Committee of the Royal College of Psychiat rists, 1997). Although there is variation, the same principles apply to the core curriculum for psychiatry at Liverpool. An overview of psychiatry in the rest of the problem-based curriculum will be presented here.
Within the problem-based learning setting, the groups are encouraged to refer to the four curriculum themes (Table 1).Thus psychosocial factors are seen as central. For each module, a convenor identifies the learning objectives. Table  2 lists the topics related to psychiatry that have been extracted from the module learning object ives document. Psychiatric issues are introduced at the earliest stage. In the first year 'basic psychiatric assessment' is a learning objective of the 'stroke' module. The 'psychological dimen sions of physical symptoms and illness behavi our' forms part of the 'indigestion module', which is the second module in the first year. Such liaison psychiatry themes recur throughout the modules. However, liaison psychiatry is not, as may have been anticipated with such an integrative approach, included at the expense of other areas of psychiatry. Substance misuse features heavily in the first year and a module in the second year is devoted to this topic. Furthermore, aspects of psychogeriatrics, child psychiatry, psychosexual medicine, learning disability, eating disorders and psychosis appear in the modules. Table 2 does not include topics that, although important in psychiatry, are of equal importance in other specialties. Such topics, which include, for example, twin studies, neuro-anatomy. team work and compliance, are too numerous to list.
This review is based on the objectives defined by the module convenor. It should be remem bered that the course in Liverpool is studentcentred. In practice, the degree to which facilitators of problem-based groups encourage adherence to the convenors' recommendations varies. The relationship between the convenors' objectives and those of the students remains to be determined.

Comment
Notwithstanding the methodological difficulties in examining problem-based learning, there is evidence of improved clinical performance, enhanced academic process and greater student and faculty satisfaction in comparison with traditional courses (Vernon & Blake, 1993). However, the value of problem-based learning in relation to undergraduate psychiatry has not been examined specifically.
Although the topics listed in Table 1are labelled 'psychiatry-related', an in-depth knowledge of these areas is not exclusive to psychiatrists. In fact, some other medical specialists or other professionals, such as psychologists, may be more familiar with certain areas. Such an overlap of educational responsibility is inevitable when analysing an integrated curriculum from the point of view of a specialist. The particular topics have been chosen as those that are of direct relevance to clinical practice in psychiatry. Although there has been a reduction in time specifically devoted to psychiatry (from eight weeks in the old curriculum to four in the new), this does not necessarily imply that undergraduate psychiatry Table 2. Psychiatry in problem-based learning modules

Model (number) Psychiatry-related topics
Indigestion (2) Asthma (4) Diabetes (5) Alcohol (6) Anaesthesia (8) Stroke (10) Wound healing (11) Smoking (13) 'Cromwell Street Murders' (14) Year 2 Pregnancy (2) Birth/lactation (3) The neonate (4) Child development (6,7) Puberty (9)2 Drug misuse (IO)2 Sexual health and behaviour (11)2 Nutrition, exercise and fitness (12) Acute abdominal pain (19) Renal failure (20) Joints and muscles (22) Old Age (23) as a whole has been compromised; this can be determined only by formal evaluation. Some may see such changes as a threat to the integrity of psychiatry. Given the explicit aim of the courseto meet the needs of future generalists -there is no attempt to maintain such integrity. Such wholesale revision of a medical curriculum produces anxieties for students and the faculty. Of particular concern is the desire for learning and assessment to be standardised.
Where does such widespread undergraduate medical curriculum revision leave psychiatrists? By the nature of their training (experiential and examination-orientated), psychiatrists should already be familiar with the philosophy under lying such a curriculum. Thus, psychiatrists can 'continue to play a major role in medical education by using their dual grounding in neuroscience and in the human aspects of medicine' (Andreasen, 1996). To do so, psychia trists need to be actively involved in the develop ment and implementation of such educational innovations. The Camberwell Assessment of Need (CAN) is a tried and tested approach to assessing the needs of the severely mentally ill which is suitable both for research studies and routine clinical use. Rigorously developed by staff at the Section of Community Psychiatry (PRiSM), Institute of Psychiatry, the CAN is suitable for use in primary care settings, specialist mental health teams, and social services. It will be of particular interest to care managers and mental health staff who wish to meet the legal requirement that the severely mentally ill receive a comprehensive needs assessment.