| Abstract|| |
In India, postgraduate (PG) training in Psychiatry began in 1941 and came under the regulation of the Medical Council of India in 1956. Since then, it has evolved into a more structured objective system. Most PG courses require compulsory submission of a dissertation work to provide experience in planning, executing, and disseminating research, in addition to clinical work, thus preparing the students to be future teachers or trainers and clinical practitioners. The training regulatory board needs to revisit the curriculum with regard to the provisions under the Mental Healthcare Act (MHCA) 2017, to incorporate the necessary knowledge, skills, and competence of trainees. The Act gives directions to the psychiatrists to act in certain ways in certain situations and makes documentation and completing forms more important. There are provisions for doing research in patients with severe mental illness with certain safeguards. The article discusses the aspects of the MHCA that necessitate modifications to the training, to equip the trainee psychiatrists to work within the framework of the act and also to familiarize them with the aspects of patient safeguards while conducting research. The trainees should take the initiative and put in efforts to understand the practical implications. Mentored learning of practical scenarios in their clinical postings is the best way to learn. Finally, one has to understand that there may be varying interpretations of the provisions of the act. Any interpretation of the provision can still be challenged in court.
Keywords: Curriculum, Guidelines, Indian Psychiatric Society, learning, Mental Healthcare Act 2017, Postgraduate training, Psychiatry
|How to cite this article:|
Harbishettar V, Murthy P. Reorientation of postgraduate training in the background of the Mental Healthcare Act 2017. Indian J Psychiatry 2019;61, Suppl S4:804-8
| Introduction|| |
In India, postgraduate (PG) training in psychiatry dates to 1941, and the Indian Psychiatric Society (IPS) formed a committee on PG medical education in the same year of its inception, i.e., 1947. The Medical Council of India (MCI) began regulating the PG training in 1956. Training is also provided through the Diplomate of National Board (DNB) courses which were established in 1975. PG training has been primarily focused on gaining clinical experience by the way of postings and communication. Training aimed to prepare the students to become qualified psychiatrists with the ability to work independently. The IPS has developed and periodically modified guidelines for PG education, and last revised it in 2013.
As per the MCI, the MD Psychiatry trainee's curriculum is for 3 years, with rotation posts, including in Neurology. The trainee is expected to learn basic neurosciences, psychology, and social sciences and spend time in clinical postings in subspecialties of psychiatry such as Addiction Psychiatry, Child and Adolescent Psychiatry, Forensic Psychiatry, Community Psychiatry, Consultation-Liaison Psychiatry, and Clinical Psychology and electives. As per the latest information, 161 institutions in India have 604 MCI recognized MD in psychiatry seats per year. DPM courses are offered by 56 institutes, with an intake of 132 seats, but the majority of the diploma seats are being converted to MD seats  As per the seat matrix from the DNB counseling from the year 2017 available on their website, there are 15 seats for Psychiatry in 12 training recognized institutes in India.
Trainees also gain knowledge in areas which are not routinely covered in their department, through personal initiatives such as the following international trends in research, attending conferences and continuing medical educations, as well as through guest faculty lectures. A resident pursuing a PG course is expected to develop a research plan in consultation with the guide/s, write a protocol, know the process of seeking Ethics Committee Approval, and learn how to gather and analyze research data, interpret the results, and present the findings of their dissertation/thesis.
The new Mental Healthcare Act (MHCA) 2017 will change the Psychiatrist's way of practice. This necessitates changes at the level of training so that the trainees will be able to practice in compliance with the law. The law, while allowing research among persons with severe mental illness, has also brought in specific safeguards for such research. The article discusses the major modifications that may be required in the current training to equip the clinician to work within the framework of the Act and also discusses the aspects of patient safeguards while conducting research.
| Changes in the Law|| |
Under the previous act, the Mental Health Act (MHA) 1987, patients with mental illness were admitted at the request from family members. In any clinical setting, during assessments and review of progress, family members were generally involved. On the other hand, in the MHCA 2017, patients' rights and preferences are given precedence. The Act gives directions to the psychiatrists to work in a certain way in a certain situation and makes documentation and completing forms important. Thus, learning objectives will need to include training on documentation.
Even when MHA 1987 was in place, courts had sought justification for taking a decision when a person's right and liberty has been taken away. However, it has been increasingly pointed out that the family's concerns may be overridden by the expressed needs of the person with mental illness (PMI) and that the latter is paramount. Such interpretations have been made by the court while a practitioner was facing charges of habeas corpus when a person is admitted against will. The circumstances and the basis for arriving at a particular decision and ability of the practicing Psychiatrist to justify the decisions before the court becomes important when a person's liberty and rights are compromised or seen to be compromised. In the MHCA 2017, where provisions based on human rights and to take the least restrictive approaches are made, the practicing psychiatrist has to be careful in making decisions that are against the person's will. Since any statement or provision of the Act is subject to variable interpretations, anyone can seek court intervention when a professional's practice is seen to contradict the interpretations. All these issues underscore the need for improved communication, adequate efforts to develop a trusting relationship with the patients and their families, and compliance with the law by seeking his/her preferences from the patient after providing adequate and necessary information. These elements are best learned during professional training. Some suggestions for changes to training with the implementation of the MHCA 2017 are discussed in this article.
| Communication Skills|| |
Interaction with patient and family
There is a need to give adequate time to PMI and their families, to have more open communication, to enhance trainee's ability to determine the patient's understanding and capacity to various issues related to care and establish the person's preference in treatment, including the setting. The trainees must seek supervision and advice from their supervisors regarding the assessment of risk, as well as in discussing the legal aspects with the patient and family. One has to be mindful of occasional conflict between patient and family's preference. The trainees may sometimes experience contradicting situations where they may have to reveal decision to admit patients against their will and in other situations, decline to admit a patient at family's request in accordance with the law. The first thing is to know is that one may have to intervene differently in different situations. Second, even while making a decision that may comply with the law, the decision taken may potentially result in either unhappy patient or unhappy family members. Such a situation should be carefully handled, and their supervisors must support the trainees.
One has to learn the art of proper documentation because it could become a potential source of evidence in case of any inquiry or medicolegal situation. The dictum is to consider every case as a potential medicolegal case and be very mindful of appropriate documentation. The Courts, Review Boards or the Medical Councils can call any doctor, including PG trainees, for clarifications or as a witness. For example, though a particular decision to treat against a person's will is to be written down, the trainee may be required to appear before the Review Board or Court to explain the basis of arriving at such a decision. The trainee must be prepared to answer why supervision was not sought in a particular case, or not appropriately recorded. This makes the supervision discussion also an important part and therefore, wherever a discussion with supervising consultants or senior residents has taken place, this has to be well documented. There has to be proactive learning and improving documentation. PG curricula, as well as per the guideline by the IPS Committee, mention that trainee has to learn the skills of documentation but has not spelled out the details., Although every doctor has a different way of documenting, there has to be some standard that needs to be followed to make the notes understandable by colleagues or other team members. The notes should include the patients' care needs, the basis for ascertaining the level of risk, the basis for concluding whether a person has the capacity or not, the preference of treatment sought with the patient, and the decision made and the justification for it. There is, thus, a need for comprehensive clerking which includes detailed documentation of discussion, including ones pertaining to the law.
| Relevant Sections of Mhca 2017|| |
This provision in the MHCA 2017 will bring changes in practice as trainees will have to learn to take informed consent from the patients even for what may be perceived as routine care. The trainees would need to practice providing information to the patients and seeking their consent. Trainees may have to learn to hold discussions with patients, where, for example, they provide a list of common antidepressants with their anticipated response and common side effects. Then, the patient is encouraged to take decisions that eventually become the treatment.
Capacity to make decisions about care and treatment
Chapter II lays out the criteria to determine whether individuals have the capacity to decide about their mental health care and treatment. Trainees are best placed to bring in the changes in clinical practice and begin assessing capacity for a particular aspect, under supervision. They should document the process and the basis for their impression and also the further plans, where they may mention the need for reassessing capacity.
Treating doctors must manage patients in accordance with a valid Advance Directive (AD). Trainees seeing patients for the first time in an emergency setting or the outpatient clinic will have to ask if a person has already got one; although, the Act has made it the duty of the patients or their Nominated Representative (NR) to make AD document accessible by the doctor when required. However, the act also says that in community settings that are not registered as a Mental Health Establishment, emergency treatment under section 94 can still be given despite valid AD. The trainees also need to be sensitive to the challenges in the implementation of the AD in our country.
Patients have the right to nominate a family member or even someone from outside the family as their NR. Despite NR's presence, the patient still takes center stage in decision-making when he/she has the capacity. Trainees need to know the provisions here and also involve the NR wherever required.
Right to Information
Under right to information, patients admitted against their will under a particular section of the act need to be provided information about the nature of the illness, treatment offered, reasons for admission, and also their rights to appeal to the concerned board. Trainees need to take the initiative and practice providing such information and documenting the same. In addition, providing written information on their type of admission; their rights, including the right to appeal; and its procedure can be seen as a good practice.
Right to confidentiality
Code of medical practice emphasizes the confidentiality of patient information. However, the Act specifies situations where this right may be overridden. For example, when a patient with mental illness poses a risk of harm to self or others due to the underlying illness, the minimum information that is necessary to protect the person from harm or violence to self or others or for public safety will have to be released to concerned parties. Information may also have to be released to courts or other statutory bodies. Releasing of information is best done by trainees only under proper supervision, but they must try to get involved to learn by first-hand experience.
Right to access medical records
Trainees need to be aware that the information they record in the notes may be scrutinized or questioned as patients can have access to their medical records. There could be several ways of documenting. For example, interpretations like “the person is threatening suicide” may be replaced with a more descriptive and verbatim narrative. Similarly, an interpretation that a patient is paranoid or lacks insight may be substantiated with an appropriate description of the reported phenomenology. Increasing replacement of detailed case notes with telegraphic electronic online documentation is likely to lead to challenges in such contexts.
Mental Health Establishment
Some trainees, after qualifying, would want to independently establish psychiatric services, including inpatient facilities. There are two aspects here: one is understanding all the requirements of the laws and policies required to set up such a center and other is their personal skills to be honed, as already recommended by the IPS committee. Trainees must, hence, adopt the approach of learner-centered learning than teacher-led teaching to self-determine learning objectives and seek appropriate counsel in such areas from their supervisors. Collateral experts, like legal experts, sociologists, etc., as well as peers and seniors, may also be an important part of this learning process. In addition to their professional skills, setting up of an independent facility will also require managerial and administrative skills, ideally learned as part of their training, to comply with the legal provisions. As sub-standard facilities run by nonqualified professionals running deaddiction and other facilities are at risk of closure, there is an increasing need for well-run inpatient facilities. Several hospitals are keen to seek accreditation from the National Accreditation Board for Hospitals and Healthcare Providers, and this may be a good opportunity for the trainees to get involved.
Mental Health Review Board
The trainees need to understand that Mental Health Review Board (MHRB) is statutory in nature and in many respects, work similarly to Court. Following an appeal by any detained “supported” patient, the MHRB will review and may choose to clarify, possibly looking through notes, or may decide to call the trainee or their supervisor involved in the patient's care, though this is not spelled out. The preparation required, collecting information to assist the review, and responding to questions by MHRB may need to be learned. In England and Wales, trainees are encouraged to represent their supervising consultant in the Mental Health Review Tribunals, which is a good learning experience. The Royal College of Psychiatrists has suggested guidelines for their trainees attending such tribunals.
Independent admission (section 86)
Regular review of the severity of illness affecting risks and capacity will be required. The best approach by the trainees would be to build rapport and work with the patient's preferences. During on calls, if they have to review a patient under Section 86, the trainees must know that any changes to medication cannot be made without taking informed consent from the patient.
One has to get familiarized with the use of sections 89 and 90. Especially when on-call duty or during a change of postings, read the case notes and discuss with staff nurses to know the type of admission and clarify where necessary before interviewing the patient or their relatives. In the case of independent admission, the assessment of capacity to decide treatment is regularly needed. Otherwise, treatment will be as per the agreement by the patient. In patients admitted under Sections 89 or 90, the NR would be involved in treatment; however, the law requires periodic assessments of capacity to decide on their treatment.
Throughout the patient's stay in the hospital, the trainee needs to regularly review to ensure that the care is least restrictive. During regular reviews, an attempt should be made to help the inpatient understand the information that is needed.
Discharge planning (section 98)
The trainees should learn to evaluate the care needs, including the need for rehabilitation, and also have knowledge of available care facilities for arranging follow-up and their suitability to the care needs. This is the ideal time to inquire if the patient wants to make an AD.
Research (section 99)
Research in persons with severe mental illness can have ethical issues, as according to Sections 89 and 90, the patients might have been detained against their will. Interviewing such patients pose ethical challenges in terms of whether they will be able to give consent. Formal assessment of capacity to enter into research has not been mentioned in Section 99. However, an ability to understand and informed consent are prerequisites to the participant's recruitment into the study. The Act provides an opportunity to conduct research even if the person is unable to give free and informed consent, by seeking permission from the State Mental Health Authority (SMHA). Furthermore, the SMHA has powers to allow research with NR's consent with some clauses which are safeguards. The Act does not restrict research from the case notes. Overall, Section 99, with the need to safeguard the patients, provides opportunities with a procedure to conduct research. It seems that getting permission to conduct research under the MHCA 2017 is not a substitute for Ethics Committee Approval and therefore, this approval should also be sought along with other obligatory requirements as per the study planned.
Police involvement (section 100)
Person wandering, incapable of caring for self or identified to be at risk to self or others, due to possible underlying mental illness, will be detained by police officer and taken to the nearest public health establishment for assessment of health care needs. During on-call duties, a patient, thus, picked up by the police may be brought to the hospital. In such situations, the assessment will have to be based on information from the patient and also an observation of the mental state. In addition, one may have to rule out a possibility of delirium or withdrawal or toxicity from substance use, as well as dementia. Such scenarios pose challenges during the assessment, and trainees must seek supervision and do appropriate documentation.
| Indian Psychiatric Society Guidelines For Postgraduate Psychiatry Training: 2013 Revision|| |
The IPS guidelines for PG training had suggested various changes in the approach to PG teaching from being discipline-oriented learning to problem-oriented learning, from being disease-oriented learning to patient-oriented learning, and from being teacher-taught to student-led learning. It had also emphasized the need to deal with medicolegal aspects of psychiatry and to acquire knowledge of medicolegal issues related to admission, discharge, record maintenance, and standards of care. There was also a specific mention of the need for proper documentation of patients' records. Arranging care for patients in collaboration with fellow mental health professionals and other health professionals was also emphasized. Along with these approaches, the specific issues as pertinent under the MHCA 2017 need to be incorporated into training. In this regard, the IPS committee on PG education will have to revise the PG training guidelines.
Regular review of one's own practice, to evaluate whether one is complying with the legislation or not, will be required. Audits, service evaluation studies, and research would help achieve this goal. IPS could consider forming a sub-committee of experts and provide medicolegal suggestions which could help its members as well as their trainees. There can also be guidelines to support doctors attending courts or MHRB, similar to the one Health Education of England has developed to support its trainee doctors attending coroner's court.
| Human Resource Development for Implementation of the MHCA 2017|| |
PG training for more than 70 years has produced about 9000 psychiatrists as of now, and it is safe to assume that more than 700 new psychiatrists are being added each year. The desired number is 3/100,000, but currently, there are only 0.75 Psychiatrists/100,000 population. With a very liberal approach taken to protect the rights of the PMI, to implement the provisions of the MHCA 2017 and also to match to international standards, the ratio of psychiatrists to the population will have to be 1:10,000, which seems difficult to achieve. The shortage of services from qualified psychiatrists may need to be overcome by providing training to the medical practitioners by the way of certification courses. Innovative use of technology, telemedicine, and other virtual platforms can be made for training purposes, like short online courses, for example, to increase the availability of human resources. The MCI may need to look at increasing the number of seats. The government should evolve strategies to retain the trained mental health professionals as well as attract those with foreign degrees and improve opportunities to encourage them to return.
| Conclusion|| |
In addition to the prescribed syllabus, it is prudent for the trainee to become familiar with all aspects of the MHCA 2017, which needs to be incorporated into routine clinical practice. Peer initiated problem-based learning is an effective way of learning the aspects of MHCA 2017 through case scenarios. The types of admission, need for the recommendation of two assessments for admission, and the process of review by MHRB are all safeguards in place to ensure a system where there are fewer chances of depriving individual's liberty and rights. Rehearsing such scenarios routinely in their clinical postings is the best way to learn, especially under guidance. Regular review to evaluate whether one's practice is complying with the legislation will be required by doing audits, and hence that one can know and work on the deficiencies. Finally, one has to understand that the interpretations of the law by the medical fraternity may not be the final one. Any provision can be challenged in court. With court judgments, there could be changes to interpretations.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Prof. Pratima Murthy
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None