A New Era in Psychiatric Education, A New Era for Education in the WPA
Allan Tasman, MD
WPA Secretary for Education
The second half of the 20th century was an era of dramatic changes in the field of psychiatry, ranging from understanding of brain structure and function to development of new systems of care. For example, our understanding of brain structure and function changed dramatically with the discovery that the brain undergoes continual remodeling, both structurally and functionally, in response to new developmental experiences. These findings, exemplified by the work of Nobel Prize winning psychiatrist Erik Kandel, have influenced not only our understanding of the brain, but have led to an entirely new area of enquiry focused on understanding the impact of the interaction between genetic function and environmental influence. In addition, we now know that stem cells that are produced in the brain provide the substrate for the development of new neurons. This finding not only challenged conventional wisdom that once neuronal death occurred there was no replacement, but has great import for an entirely new future line of therapeutics.
The 20th century was a time of dramatic change in individual treatment approaches considered from both a psychological and somatic point of view. The development of psychoanalysis in the early 20th century stimulated an incredible period of development following World War II of a wide range of psychotherapeutic treatments encompassing both psychological support and understanding of psychological forces affecting behavior, thought, and emotions of which the individual may be initially unaware. Advances in modern somatic treatments that began early in the 20th century were influenced, for example, by the development of ECT. Then, in the early 1950’s, the era of modern psychopharmacology began. Now investigators are exploring a variety of treatments which modulate neuronal function in specific areas of the brain, either directly or via changing genetic expression.
At the level of service systems, dramatic changes have occurred as well. Modern hospital psychiatric treatment is now most commonly found in the context of a general medical-surgical hospital setting rather than the historical isolated and free standing psychiatric asylums. In addition, community based systems of care outside the hospital have been widely implemented since the 1960’s.
Changes in diagnostic classification over the last several decades have also led to the ability to more appropriately discern the nature of the psychiatric problems faced by individuals in our care, which leads to better treatment. The advances in diagnostic classification are marked by the changes in the International Classification of Disease from the World Health Organization, and in a number of other national systems. One of the best known of these involves the ongoing revisions of the Diagnostic and Statistical Manual from the American Psychiatric Association. The ICD and DSM, however, represent only two of a wide variety of diagnostic systems used around the world. The impact of all of these, however, has been a trend toward more consistent diagnostic decision making across clinical settings.
While there are dramatic differences among regions of the world and between developed and less developed countries, there is little doubt that the modern psychiatrist must have available a wide range of knowledge and clinical skills to provide optimal care based on present state of the art knowledge.
Psychiatric educational programs also have changed dramatically over the last decades to incorporate the need just discussed for the modern psychiatrist’s knowledge and clinical practice. While provision of services to those with psychiatric illnesses is substantially influenced by national mental health policies, culture, and local traditions regarding the structure and provision medical and mental health services, there has been an increasing move toward standardization of psychiatric training around the world. These trends will continue to be, for the foreseeable future, balanced with local traditions, culture, and medical systems. It is incumbent upon those involved in training the next generation of psychiatrists and other physicians to ensure that trainees are exposed to the widest possible range of clinical settings so that they can develop appropriate clinical skills based on cutting edge knowledge. It is within this context that the World Psychiatric Association has developed an array of educational programming geared toward ensuring psychiatrists, other physicians, and the general public, no matter where in the world they live or train, will have the advantage of the latest understanding of psychiatric illness etiologies, diagnosis, and treatment. Let me review these projects and initiatives in greater detail.
I have mentioned the wide array of advances in our profession and the need to ensure wide access to cutting edge knowledge for psychiatrists around the world. A major aspect of this challenge will be to assist psychiatrists in benefitting from knowledge gained from our latest scientific advances. Translational research, which addresses this need, has become the description for this essential mission for all of medicine. Clearly, there is a need to better make available information which will allow practitioners to apply research advances to the clinical setting in all areas, but particularly in low resource settings. There is thus an urgency to develop educational programming to meet this need.
Historically, the WPA has developed educational materials seeking to highlight specific aspects of our field’s knowledge base. This has resulted in a variety of educational materials which have been disseminated, not only in written form, but also made available on the WPA website (www.wpanet.org). At the present time, the interested reader can find a variety of these materials on the WPA website. Descriptions of several of these projects will illustrate the historical approach.
The project entitled “Teaching and Learning about Schizophrenia” is presently available on the website in a variety of languages. In addition to English, there are versions in Czech, Bulgarian, Georgian, and Spanish. This program contains an extensive series of slide sets which can be used for either individual learning or within an educational setting in a seminar. The program is divided into several modules. The first deals with “Clinical Presentation” and includes the topics: history of the concept of schizophrenia, current definitions and criteria according to ICD and DSM, differential diagnosis, laboratory work up, psychosocial evaluation, course and outcome, and cross cultural issues. The second module, “Pathophysiological Mechanisms”, includes the topics of: epidemiology, genetics, neuropathology, neuroimaging, neuropsychology/cognitive psychology/ cognitive neuroscience, neurophysiology, and non genetic factors. The third module, focused on “Treatment”, includes sections on somatic therapies and psychosocial therapies. Finally, the fourth module is a series of clinical case vignettes to illustrate different aspects of this illness.
Another example is the project on social phobia, presently available in both English and Russian versions. This project includes both introductory clinical information for the clinician and two additional workbooks for use with patients.
A recent education project is the WPA/International Society for the Study of Personality Disorders program on personality disorders. This project is now only available in English. Personality disorders are among the more complex problems that psychiatrists must address. Professor Eric Simonson and colleagues have produced a work that is comprehensive, but organized in a way that makes access to the material easy for individuals at any stage of their professional careers. The work is designed in three modules. Module One addresses conceptual and methodological foundations, reviews the scholarly contributions to our understanding of personality and how we might classify personality and personality disorders, and reviews a variety of therapeutic management approaches. Module Two addresses each personality disorder and reviews diagnostic criteria, etiology, epidemiology, comorbidity, and treatment. Module Three presents a case book to illustrate the range of personality disorders. The vignettes are concise, yet illustrative and accompanied by expert commentary. Recommended readings and curricular recommendations are also included for all three modules.
Visitors to the educational programs sections on the WPA website will also find the original version of the WPA educational program on depressive disorders. This set of educational materials is available in Japanese, Spanish, Portuguese, and Bulgarian. However, soon after the publication of this issue of World Psychiatry, readers will find that a new and completely revised edition of the educational program on depressive disorders is available. Presentations of this work occurred at several WPA international congresses, and the official launch took place in two, three hour sessions at the 2008 World Congress of Psychiatry in Prague. This project, like others, is set up on a modular basis, with accompanying slides. Translations into Spanish, Russian, and Arabic are already in the process of being commissioned, with further translations into German, French, Chinese, and Japanese on the agenda.
In addition to topics focused on specific disease entities, the WPA, in collaboration with the World Health Organization, prepared an ICD training kit for professional education about the International Classification of Disease Section on Mental and Behavioral Disorders. This is an extensive training program which includes not only text and slides, but also case histories to illustrate a variety of disorders, and an appendix containing resource documents, rating scales, and articles of interest.
At the June 2009, executive committee meeting, the WPA Executive Committee approved the Education Committee’s project entitled, “Recommended Roles for the Psychiatrist in First Episode Psychosis”. This project is also available on the WPA website under “Educational Resources”. This document was prepared to provide psychiatrists with guidance regarding the most recent developments and the conceptualization regarding knowledge of psychosis onset, and the implications of these findings in early detection and effective intervention strategies. There has been an increased awareness over the past decade that by the time many patients with severe mental illnesses reach psychiatric services, the person has often been disturbed for many years. During that period of time, without treatment, a great deal of additional personal and interpersonal distress and psychosocial decline may have occurred. Such findings are certainly true in the case of psychosis. The implication of this situation is that services need to be organized to enhance the ability of people with psychosis receiving help much earlier in the course of illness.
The guidelines on roles for the psychiatrists in first episode psychosis have been written by experts in the field to assist psychiatrists in every country of the world to consider their roles in providing these services, to assist in psychiatrists’ professional development of these services, and to help familiarize psychiatrists with contemporary thinking about first episode psychosis and the importance of early detection. The document also reflects the knowledge that a broad range of professional skills are needed to adequately care for patients and their families. References are provided for further reading on the subject. The guidelines complement the recent forum on early detection in psychosis that was published in World Psychiatry in the 2008; 7 (3): 148-156 edition. The Chairperson of the guidelines group is Dr. Brian Martindale, who can be contacted at firstname.lastname@example.org. Dr. Martindale and colleagues are interested in assisting progress in translation of the guidelines, as well as providing consultation to those working to implement those guidelines in their local setting.
While these specific disease and diagnostic related educational programs are important, the WPA has, because of its international scope, a major opportunity to play an even more effective role in developing ongoing educational programming. Therefore, an important component of the 2008-11 WPA Action Plan is a complete revision of the WPA curricular recommendation for medical student and resident education. The original projects reflected a great deal of work by leading international educators, but the programs are now around a decade old, and are, therefore, out of date. The goal of this project is to ensure that the material is useful for those teaching in a wide range of programs around the world, with extremely variable resources. In addition, it is clear that there is a great diversity of both undergraduate and graduate education requirements in various countries. One of the major aims of the project is to highlight an ideal approach which may be useful in areas in which there are no national requirements to use as a template for recommended educational requirements. In addition, the material will be developed in a way that will be useful, not only in low resource areas, but also in high resource areas, not only as a tool to be used to advocate for more resources and stronger educational requirements, but also to provide assistance to develop programming in situations where educational resources in the form of facilities, clinical settings, and teaching expertise may be less available.
Another important aspect of the project is that the previous project was limited to brief descriptions of various aspects of clinical setting recommendations and curricular topics. The program presently being planned will have material presented in greater depth in hopes of being more useful in developing educational programs in present day settings. In addition, advances in various educational approaches, such as competency based education and evaluation, were not covered in the previous works because these approaches did not exist at the time these commendations were formulated. Thus, providing additional resources to help develop and structure educational programs and evaluation systems will be an important part of this project. When completed, the initial work will have text and visual materials, and will also be posted on the WPA’s website. In addition, it will be translated into the major languages of the WPA so that it can be used in every setting around the world. If funding is available, the WPA may be able to sponsor an ongoing series of educational consultations and training programs throughout the world.
Another important component of future educational programs will be to develop ways to take advantage of existing and future technologies. For example, interactive computer based education and telemedicine based educational programming are not in much use in any of medicine in any part of the world. Because of the international scope of the WPA, we are in an excellent position to develop such approaches. The WPA can then pilot test them around the world in order to ascertain the optimal educational approaches using these modern technologies.
As a starting point to assess the use of technology in education, we plan to develop a series of online Continuing Medical Education (CME) programs based on lectures presented at WPA International Meetings and World Congresses. Those who attended the recent WPA International Congress in Florence in April, 2009 will know that there was an outstanding lecture series of internationally recognized leading academic clinicians, researchers, and educators. Arrangements were made to produce high quality video tape recordings of the main lectures presented in the Florence congress. At the present time these video tapes are being reviewed and prepared for posting on the WPA website. Thus, psychiatrists who were unable to attend, either because of time or resource constraints, will be able to take advantage of outstanding educational lectures. We also intend to develop online, interactive continuing medical education (CME) review questions so that psychiatrists watching the lectures and using the CME questions will have the opportunity to gain continuing medical education credit. We anticipate that this project will be quite successful, and we plan to use the responses to this initial effort to help us to refine and expand the program over the next several years. This will be a first step in developing more regional or local based telemedicine or interactive computer based educational programming through the auspices of the World Psychiatric Association.
Another example of plans to use technology in education is another ongoing project of the WPA Education Committee. Under the leadership of Dan Stein in South Africa, the Education Committee has been overseeing the preparation of a series of chapters which will develop into a Wikipedia based medical student textbook of psychiatry. Wikipedia is an online, free encyclopedia which has now expanded its scope to include books and textbooks. While this program has not yet received official WPA endorsement because it is not yet complete and submitted for approval, interested individuals can visit the Wikipedia website of the present draft version, which is http://en.wikibooks.org/wiki/Textbook_of _Psychiatry. Several draft chapters have been prepared and are already posted on the Wikipedia website, so that colleagues will be able to have an idea of how the project will look when it is finally completed and approved.
Because in many parts of the world there are inadequate mental health resources to provide needed care, psychiatric educational initiatives geared toward primary care physicians, nurses, and physician’s assistants are needed. This important goal is addressed in a variety of ways in the 2008-11 Action Plan, one of which is under the direction of the Education Committee. When the revision of the WPA Depression Education Program was undertaken, an important aim was to make the new materials useful in the primary care setting. There is strong research evidence that depression is often inadequately recognized, or if recognized is inadequately treated, in the primary care setting. In the U.S., for example, as many as 50% of uncomplicated cases of depression go undiagnosed in the primary care setting. Thus, an important part of the overall project will include collaboration with other organizations, such as the World Association of Family Physicians, to modify our material in a manner suitable for use in a primary care setting. An ongoing series of educational symposia or conferences focused on diagnosis and treatment of depression will be organized if further finding support can be identified.
As we all know, stigma about mental illnesses and about psychiatrists and other mental health professionals has been a major problem in impeding individuals from seeking help early in the course of psychiatric illness when we can be of most help. To address this issue, the 2008-11 WPA Action Plan also has as a major priority the development of a new section of the WPA website focused on public education. The eventual product will be a separate section of the WPA website on public education with materials available in the major WPA languages and with links to public education materials from WPA member societies, all in the languages of the home country. In addition, it is envisioned that these links will also contain WPA developed public education material in the native language of the local country. Further, selected materials from national societies will also be obtained with the societies’ permission for downloading directly on the WPA website. Thus, when the project is completed there will be three components: 1) WPA’s own materials developed in the major WPA languages, 2) selected material from member societies directly available on the WPA website with the permission of the societies, and 3) links to the public education materials from every member society which has such material available. For those societies which do not have their own materials, WPA will provide assistance through the use of the WPA’s developed material, with the plan that these materials will be translated into the member society’s major language(s). In addition, it is anticipated that it will be important for modifications to be made by every member society in order to be culturally sensitive to the home country.
We have an extensive and ambitious agenda for the development of our educational programs over the coming years. This is essential for the field, as the pace of change within psychiatry is rapid and dramatic. Anyone interested in assisting with any aspect of our projects is encouraged to contact me, Allan Tasman, WPA Secretary of Education. These are exciting times for the future of psychiatric education, and collaboration with as many of you as possible will make our progress even more impressive.