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|Year : 2020
: 62 | Issue : 6 | Page
|Need and learnings from having psychiatry as major subject during medical graduate examination
Anindya Das1, Vijay Krishnan1, Vishal Dhiman1, Jitendra Kumar Rohilla1, Vikram Singh Rawat1, Aniruddha Basu1, Ravi Gupta1, Ravi Kant2
1 Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Director and CEO, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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|Date of Submission||26-Dec-2019|
|Date of Decision||12-Feb-2020|
|Date of Acceptance||29-Apr-2020|
|Date of Web Publication||12-Dec-2020|
|How to cite this article:|
Das A, Krishnan V, Dhiman V, Rohilla JK, Rawat VS, Basu A, Gupta R, Kant R. Need and learnings from having psychiatry as major subject during medical graduate examination. Indian J Psychiatry 2020;62:723-7
|How to cite this URL:|
Das A, Krishnan V, Dhiman V, Rohilla JK, Rawat VS, Basu A, Gupta R, Kant R. Need and learnings from having psychiatry as major subject during medical graduate examination. Indian J Psychiatry [serial online] 2020 [cited 2021 Jan 22];62:723-7. Available from: https://www.indianjpsychiatry.org/text.asp?2020/62/6/723/303186
Recent curriculum proposed by the Medical Council of India mentions that the objective of the Indian Medical Graduate (IMG) program is to prepare the physicians of first contact, which is also globally relevant. Psychiatric disorders are quite prevalent in the community, and many such disorders are more common than other medical disorders as shown in the National Mental Health Survey and National Family Health Survey from India.,, Psychiatric disorders are not disorders of exclusion without any “organic” basis, as commonly believed. Instead, they originate in neurobiological perturbations and hence, are frequently comorbid with a variety of medical disorders. Despite the fact that a high number of psychiatric patients attend primary care, the World Health Organization report emphasizes the existence of a significant treatment gap. The main reason for this gap is assumed to be low detection rates and a lack of priority given to these disorders. The reason for low detection rates in the Indian context could be inadequate emphasis given to psychiatry during IMG training program as competencies in psychiatry are expected to be achieved during internship.
Emphasizing knowledge and competencies related to psychiatric disorders by having it as a major subject during graduate curriculum serves multiple purposes – addressing mental health gap, optimal care of patients, reducing stigma, and lastly, encouraging research.
| Learning From International Curricula|| |
Most of the international universities teach psychiatry during undergraduate years with a focus on neurobiological models of behavior and psychiatric disorders along with clinical postings.,,, Thus, at international level, psychiatry is given enough weightage in the medical graduate curriculum with a focus on understanding psychiatric disorders as integral to the rest of the medical disciplines.
| Psychiatry as a Separate Subject: Initiatives At All India Institute of Medical Sciences, Rishikesh|| |
Considering all these facts, leadership of the All India Institute of Medical Sciences, Rishikesh, proposed to have a separate examination of psychiatry during medical graduate education after due administrative approvals. The examination was planned during the third professional (at the completion of the seventh semester). Following approval from competent bodies, the faculty of the department of psychiatry was given the herculean task to design and roll out the curriculum based on a number of parameters – need of nation, following contemporary concepts which are applicable at global level, developing conceptual thinking, and preparing IMGs to serve multiple roles – ranging from primary care physician to a specialist, from a medical teacher to a physician scientist, and, lastly, from policy implementer to policy designer.
| Ideas Feeding Into the Development of Curriculum|| |
Faculty members of the department looked for updates and publication patterns in leading journals of medical education,,,, and psychiatry.,, In addition, leading books of psychiatry were also consulted., Considering the issues that lead to marginalization of psychiatry within medical disciplines, faculty members felt that the curriculum must encompass the explanation of psychiatric disorders based on the medical model that includes neurosciences, genetics, and pharmacotherapy., Various subspecialties in psychiatry, namely addiction psychiatry, geriatric psychiatry, child and adolescent psychiatry, neuropsychiatry, consultation liaison psychiatry, and, lastly, sleep medicine were included so as to provide a bird's eye view of the ramifications of psychiatry to the IMG. At the same time, consideration was given to the role of psychological sciences, particularly the principles of widely practiced cognitive and behavioral techniques. Similarly, orientation to social determinants of health, global movement for mental health, mental health service system, and preventive approaches including the role of public policy in prevention were also included. Finally, considering the burden of other subjects on IMGs, the syllabus was carefully trimmed in proportion to the prevalence of psychiatric disorders encountered in general practice.
| Transfer of Contemporary Knowledge of Subject|| |
Transfer of knowledge is divided into two modes – theoretical knowledge as well as practical skills. Forty interactive theory classes were planned starting from clinical vignette and moving back to neurobiology, and then discussing management issues. For transfer of clinical skills, students have 4 weeks of clinical postings across two semesters. The 1st week of posting is largely focused on the art and science of history taking and clinical interview, analyzing the data emerging out of history, clinical examination, and interpretation of laboratory investigations. The next 3 weeks of clinical posting are focused on the practice of previously learned skills to develop differential diagnoses as well as to plan short-and long-term management. Further, due care is taken to encourage conceptual thinking and analysis. For example, they are explained the common underpinning of various disorders falling in each of the categories. Similarly, students are encouraged to understand disorders as dysfunction in various domains, namely mood disorders affecting the four domains of mood, cognition, psychomotor activity, and vegetative functions. In addition, the training also includes interpretation of investigations (electroencephalogram [EEG], neuroradiological, and other laboratory investigations, wherever required), converting clinical and laboratory information to a clinically meaningful diagnosis and planning initial management.
| Assessment Method|| |
Formative and summative assessments are carried out for students, with each carrying equal weightage. It is done so as to ensure that the assessment is not based on a single day's performance. Moreover, it gives support to students who are consistent but has a “bad-day” during the professional examination. Formative assessment is done at the end of each clinical posting largely to assess interviewing skills. Theory and skills assessment is again done during preprofessional examinations to rehearse for finals. As per the prevailing norms, the final examination consists of theory as well as practical skill assessment. Four examiners, two internal and two external, are involved in the assessment process. The details of the assessment presently followed are described below, though we understand that the optimal assessment process is an ever-evolving field.
Knowledge assessment during preprofessional and professional examinations
Theory assessment consists of 200 clinical vignette (along with illustrations – laboratory reports, EEGs, magnetic resonance imaging [MRI] scans etc.)-based multiple-choice questions (MCQs), directed to assess the analysis of data rather than recall. All topics taught during training are divided into four sections, and each examiner is responsible for designing MCQs pretaining to sections allotted to him. This method ensure a thorough and in-depth assessment of knowledge.
Skills assessment during preprofessional and professional examinations
Practical assessment is designed in a manner so that students are examined across different aspects of skills and competencies. It is divided into three sections: case presentations, objective structured clinical examination (OSCE) for focused tasks, and spotters. Objective structured long examination record (OSLER) systematically assesses students across all areas and reduces lumping students in the average category, and OSCE was used to assess competencies for which patients are not available during examination.,
Finally, students are evaluated on five spotters from the undergraduate (UG) curriculum of psychiatry to have a well-rounded assessment. They are expected to analyze the given clinical information in association with one of the following – (i) EEG; (ii) computed tomography (CT), or MRI scan of the brain, which is part of UG curriculum internationally; (iii) functional neuroimaging – single-photon emission CT of the brain – specially to identify areas of hypometabolism in common conditions such as dementia and depression; (iv) findings on polysomnography (hyponograms, epochs showing respiratory apneas) as sleep disorders are common and have huge health and economic impact; (v) photographs of stigmata (loss of hair in trichotillomania, ash leaf spots, and Shagreen patches of tuberous sclerosis); (vi) videos of clinical findings (tics or disorientation); (vii) instruments used in neuromodulation, sleep disorders, and substance use disorders; (viii) drugs used in psychiatry practice; and (ix) laboratory reports. The multidimensional assessment helped students to balance weak domain against strengths. We are aware that the rigorousness of the assessment process might be detrimental to other centers but one can be modified as per local needs and resources.
| External Examiner'S Perspective|| |
One of the examiners noted that some of the examinees were serious and showed excellent grasp of knowledge and skills essential to psychiatry. However, others had inadequate knowledge of the management of common mental disorders. Another examiner conveyed that students were able to differentiate broad categories of psychiatric disorders, which was unlike IMGs of a similar level in most of the medical colleges. They also had desirable knowledge regarding medications and were able to formulate plan required at the primary care level. However, the art of history taking to include relevant information and filter out unnecessary information needs to be strengthened. External examiners hoped that in future, as training would be more structured, this issue would be resolved. Finally, a need for greater exposure to cases falling under the gamut of anxiety disorders, depression, and insomnia, which are more common in practice, was felt.
Both examiners conveyed that taking examination for IMG was a novel experience for them and found that the examination process was satisfactory.
| Student'S Perspective|| |
After the result was declared by the institute, some of the students were randomly selected and asked to provide their comments regarding separate examination based on the following four major points:
- Did it improve your knowledge compared to your colleagues?
- Did it change your perspective about psychiatry? If yes, how?
- Positive points regarding the method of examination that you have observed
- Do you think any improvement is required in future in the examination process?
Most of the students reported that this examination improved their knowledge. For example, “Yes, psychiatry as a (separate) subject improved our knowledge.;” “since we devoted more time to it, probably we are at an advantage;” “…good initiative, but also increasing number of subjects put more burden on us to pass the exam;” “has given us an extra edge as compared to previous batches…”
Most of the students recognized that separate examination for psychiatry changed their perspective and would help them in future. For example, “Yes it changes our perspective.it's not just a separate subject but its knowledge is useful in managing patients of medicine or any other department.;” “before exposure to psychiatry there is an image in mind that psychiatry is about treating intellectually disabled patient with drugs or pharmacotherapy but after reading we have learned about human behavior, its bearing on mental health and realized the importance of various behavioral techniques which can be used along with pharmacotherapy to treat patients….”
To our satisfaction, most of the students found examination method satisfactory. For example, “Observed OSCE was a good aspect, I recommend it to be introduced to students early so that they are made to understand and practice too…,” “Method of practical exam was good… covering all aspects from short OSCE to long case, which are helpful in clinics;” “Fair, with different sets… and in practical we were assessed briefly on each component which was very nicely planned;” “Various stations from counseling a patient to case presentation which was wonderful in itself. One thing I personally liked the most was that video of the patient of vocal tics …so overall it was good.”
However, almost all students felt that theory examination was tougher than they expected. For example, “level of Psychiatry theory exam was tough… unable to solve the 200 questions in 3 h. As the length of the questions was quite long… and the level was also tough. This was our first exposure to psychiatry…;” “it is very tough as compared to what we were taught…;” “in theory exam plenty of MCQs were too hard to answer….”
Some students felt that practical examination also had some scope for improvement. For example, “OSLER structure should be improved, rather than having same patient multiple times which irritates the patient too…;” “decreasing the number of stations and hence the duration….”
| What Was Learned From This Exercise?|| |
The most important reflection was the feasibility of having such an assessment during the UG program. Students too welcomed psychiatry as a separate subject. During anonymous feedback, they reported that because of examination, they were motivated to acquire knowledge and skills, and it had changed their perspective toward psychiatry. Reportedly, neurobiological basis (by including neuroradiology, neurophysiological parameters, and laboratory reports in assessment) of psychiatric disorders helped to clear some misconceptions.
Reflecting upon the examination process itself, examiners were of the view that this was broadly a valid and robust method of assessment, albeit one that will require modification with emphasis on common psychiatric disorders and inclusion of teaching in outpatient department settings in addition to inpatient department.
The use of clinical vignettes in MCQs, although labor intensive to design, is known to examine multiple aspects during the assessment and bring uniformity in the assessment process. In terms of performance in the practical portion of the examination, the assessment philosophy was one in which a number of relevant domains were tested. The use of various elements (OSLER, OSCE, and unobserved stations) meant that the students are tested both in their ability to elicit (OSCE; also, OSLER) and communicate (OSLER) their findings. Each of the methods of examination has its own strengths and limitations, hence, combining multiple techniques is advisable for the assessment of multiple aspects of competencies. To our satisfaction, examiners as well as examinees were satisfied with the method opted.
Particularly, this examination showed a need to further emphasize conditions and situations that the IMG is likely to face, such as depression, anxiety disorders, insomnia, and alcohol use disorders. Practical aspects of assessment and medication management (including names of medications, dosage, and side effects) may need to feature more prominently in clinical and theoretical teaching. It was felt that psychiatric teaching must ensure a balance between the inpatient setting (where students have the opportunity to develop history taking and examination skills for detailed assessment) and exposure to outpatient settings where the caseload more closely resembles that which they would see in primary care or general medical settings.
This was also an opportunity to reflect on modifications that were made to improve outcomes to the teaching scheme as well as the assessment process. It is important to note that these changes were at a stage of informal discussion within the department, given the short time that has been provided to the department to prepare for taking psychiatry as a major subject in undergraduate medical training.
| Shortcomings and Ways to Mitigate Them|| |
No intervention can be without any shortcomings, so it is true for the very fact whether psychiatry should be a separate subject during the UG medical curriculum. It becomes especially pertinent when IMG has to study 16 other subjects in a short span of 4½ years. However, as already discussed, considering the high-prevalence, basic knowledge of psychiatric disorders with an emphasis on common psychiatric disorders is the demand of the hour. This additional burden may be compensated by pruning some of the areas that are not as important from other subjects. Second, the assessment method that we adopted might appear too rigorous and structured, however, we would like to submit that we assessed only what was taught and was available to us. Having assessment in varied domains also ensured that students could understand the contemporary concepts of psychiatry and might consider to opt psychiatry as a career. Third, there might be chances that other medical disorders might be missed for psychiatric disorders by the students, however, this could be dealt with proper training and adequate exposure to medicine clinics prior to psychiatry posting. Finally, organizing examination as a separate subject for IMG is a demanding and resource-intensive task, particularly OSCE requires prior planning. This is especially in view of the increasing number of students in a batch and essentially difficult in colleges where departments are small.
| Conclusion|| |
The importance of this report is to highlight a landmark event in the history of Indian Psychiatry – to our knowledge, this is the first time that psychiatry has been directly assessed at a university level with theory and clinical assessments at par with other subjects. We believe that a description of those factors that enabled such an initiative may be useful to other medical teachers within the psychiatric faculty, in duplicating or improving upon our efforts. Strong institution-level leadership, an emphasis on curriculum development and delivery, and assessment processes that are geared toward outcomes relevant to general medical practitioners, are worth highlighting in particular.
The outcomes of the first such exercise have been extremely encouraging and provide us with a platform on which to further improve.
We acknowledge the support of Dr. Piyush Verma, Dr. Anita Verma, Dr. Shinjini Chowdhary, Dr. Rahul Verma, Dr. Kaustav Kundu, Dr. Bhavika Rai, Dr. Akash Kumar, Dr. Yogesh Arya, and Dr. Shubham Jhanwar, resident doctors in the Department of Psychiatry, AIIMS, Rishikesh.
We are also thankful to external examiners Professor Lalit Batra, Department of Psychiatry, SMS Medical College, Jaipur, and Dr. Ravindra Rao, Additional Professor, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Ravi Gupta
Department of Psychiatry, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None