Experts in psychiatry from Hong Kong, India, Indonesia, Malaysia, Pakistan, the Philippines, Singapore, Taiwan and Thailand gathered for a workshop entitled “Unmet needs in medical education for young psychiatrists”, in Kaohsiung, Taiwan. The group discussed the unmet needs of young psychiatrists, particularly in Asia.
Professor Norman Sartorius, President of the Association for the Improvement of Mental Health Programmes, delivered a keynote address to the workshop which consisted of presentations and group discussions supported by data obtained through pre-workshop surveys completed by participating clinicians. The following are highlights from this workshop.
Is current formal training adequate to prepare young psychiatrists for clinical practice?
The current content for postgraduate training in psychiatry consists mainly of theoretical and practical instruction on diagnostics and rules of classification, and the treatment, of mental disorders.1 This is supplemented by observational learning via shadowing of teachers and senior psychiatrists on day-to-day activities, and contact and incidental learning from health service staff.1 This spectrum of knowledge and skills development training is commonly observed in countries around the world, including Asian countries such as Hong Kong, India, Indonesia, Malaysia, the Philippines, Pakistan, Thailand, Taiwan and Singapore.1,2 In fact, this is extended to post-completion of training as a form of continuing medical education (CME).1,2
“There is a residency training for board certification for psychiatry trainees, and a Clinical Fellowship in Child and Adolescent Psychiatry and overseas training/education post-completion of training”Prof. Dr Manit Srisurapanont (Professor at the Chiang Mai University and Executive Member of the Royal College of Psychiatrists of Thailand)
“We have a 5-year programme with inpatient and outpatient rotations, rotations at the psychotherapy clinics, continuity clinics, and in all the major sub-specialities of psychiatry, including forensic, addiction, child and adolescent, CL, psychogeriatrics, community psychiatry, [and] emergency psychiatry. Rotations in general medicine and neurology are mandatory. Psychiatry trainees will need to take intermediate (MMed (Psychiatry) and/or MRCPsych) and exit exams. Following completion of training, there is on-the-job training, peer-review learning, participation in journal clubs, grand ward rounds and other CME activities.”Associate Prof. Dr Mok Yee Ming
(Consultant and Chief at the Department of Psychiatry, Institute of Mental Health, Singapore)
However, are young psychiatrists truly prepared for what they will face entering into clinical practice? Are they well supported over time with the skills they need for their day-to-day activities?
In 2009, the Union Européenne des Médecins Spécialistes (UEMS) described the profile of psychiatrists as experts in their therapy area, clinical decision-makers, communicators, managers, health advocates, scholars and professionals.3 This accurately sums up the expectation of these clinicians, reflecting their daily tasks and responsibilities.1 Psychiatrists are expected to (1) possess a sufficient level of knowledge as a specialist and as a member of the medical profession, (2) have a positive attitude concerning their profession and tasks and (3) possess the ‘skills of the trade’, including listening, social networking, leadership, managerial skills and treatment skills, a number of which may not necessarily be provided by their formal training.1 Professor Norman Sartorius, stated that “Skills on areas such as how to be a leader and manager, and how to network are lacking in the formal training curriculum”. The survey and discussion conducted with experts in this workshop further affirm this gap in the region.2
“We need to train young psychiatrists/psychiatry trainees to be advocating stakeholders, that is to know how to deliver ideas and they can get accepted.”Dr Margarita Maramis, PhD
(Psychiatrist at the Department of Psychiatry, University of Airlangga, Surabaya, Indonesia)
“Leadership training and training of trainers (supervisors) in psychiatry are some areas for further improvement for medical education of young psychiatrists/psychiatry trainees.”Prof. Dr Nor Zuraida Zainal
Head of the Psychological Medicine Research Group of University of Malaya [PARADIGM], President of the Malaysian Psychiatric Association, and Editorial member of the Malaysian Journal of Psychiatry
In essence, trainees in psychiatry may chance upon a teacher who has the ‘gift of teaching’, or a senior psychiatrist with good management skills during the course of their training, but may not necessarily know how to replicate these skills without being provided with training relevant for these tasks and the tools that help their performance. Ways of teaching others and good management skills are examples of things that are currently taught through imitation or not at all.1 This underscores a critical unmet educational need of young psychiatrists today.
Initiatives can be taken to expose students to the daily tasks of a psychiatrist during postgraduate training, but can we do more?
Unmet needs of young psychiatrists in Asia
Asia is a part of the world characterised by its great diversity. This is no different with respect to the specific needs of young psychiatrists in this region. Contributions from experts during the workshop revealed needs for training in soft skills for young psychiatrists that are not provided in formal training, such as subspecialty training and skills for research, literature reading and publishing (Figure 1).2
Figure 1. Unmet educational needs in young psychiatrists in Asia, as identified from the workshop and pre-workshop survey.
A compilation of information about unmet educational needs highlighted by experts in psychiatry (n = 15) from Hong Kong, India, Indonesia, Malaysia, Pakistan, the Philippines, Singapore, Taiwan and Thailand (see Reference 2 for further information on participating experts).
Among the unmet needs, acquiring skills of leadership, management and teaching were consistently mentioned as important areas for further improvement in education.1,2
“In Indonesia, despite the presence of 10 faculties of medicine with residents in psychiatry, some gaps in knowledge competency are still present among young psychiatrists in areas such as psychotherapy, forensics, and child and adolescent psychiatry, due to the lack of, and uneven distribution of, specialists and lecturers in this field.”Prof. Dr Nurmiati Amir
(Psychiatrist at the Department of Psychiatry in Ciptomangunkusumo National General Hospital, Vice-chairman of the Section on schizophrenia of the Indonesian Psychiatric Association [IPA] and Scientific Coordinator on the bipolar disorder section of IPA)
Training young psychiatrists in leadership skills facilitates their work in several areas. This include the engagement of staff in their daily task of patient care, and bringing forth talent and initiative in the people with whom they work.1 The wider impact, particularly pertinent in countries with few psychiatrists in practice, includes the ability to engage key stakeholders in programmes, and to leverage opportunity to participate in developing public health approaches to psychiatric issues and networks of care for mentally ill patients.1,2
Skills in management are often not an element of formal teaching. These skills are usually acquired through experiential learning when psychiatrists are entrusted with leading team(s) and managing multiple tasks concurrently.1 Skills training supplemented by observational learning from seniors or teachers who are good managers would significantly support young psychiatrists entering or newly entered into clinical practice.1
Psychiatrists are expected to supervise trainee psychiatrists, train medical students and other staff, and educate family and/or care givers about living with a person with mental health issues.1
“Young psychiatrists will become senior teachers in several years. They need to be equipped with better presentation skills and broader scope of knowledge in psychiatry. As such, any task or effort which could improve these two main targets will be highly appreciated by junior psychiatrists.”Prof. Dr Yan Kuang Yang
(Distinguished Professor at National Cheng Kung University & Hospital)
Teaching is a skill that, once acquired, has many valuable outcomes relevant to the future of psychiatry.1 Among them is the capacity to change the image of psychiatry and to attract students to select psychiatry as their profession – a task of great importance in view of the lack of psychiatrists in Asia, as highlighted by Professor Sartorius.1
Bridging the gap
There is a clear need to address the gap that remains in formal training. However, given the diversity in education in Asia, the first and foremost necessity is for Asian key leaders in psychiatry to drive and prioritise the standardisation of competences for young psychiatrists, as highlighted by both Dr Edgardo Juan L. Tolentino Jr, Chief of the Section of Psychiatry at Makati Medical Center and Immediate Past President of the Philippines Psychiatric Association, and Dr Chan Herng Nieng, Consultant at the Department of Psychiatry in Singapore General Hospital.2
It is clearly important to provide skills training in areas that are currently not addressed through formal education. Discussions with therapy area experts indicated that the curriculum should be tailored to train young psychiatrists using skills that will help them to practice.2 These can be knowledge updates (as opposed to refresher courses), teaching of skills in the management of mental illnesses pertinent to the region, skills of appraisal in the critical evaluation of literature, and in social networking.2 The curriculum should equip young psychiatrists with skills in leadership, management and teaching.2 Furthermore, education should continue after these clinicians start their practice, to make certain that they are well supported.2
To ensure the success of these educational initiatives, they should be engaging/interactive – leveraging the use of multimedia and technology – have a structured delivery and, importantly, provide participating psychiatrists the opportunity to accumulate CME points.2 Additionally, insights from Associate Prof. Dr Pornjira Pariwatcharakul, Associate Professor at Mahidol University, Thailand, revealed that the involvement of young psychiatrists in the delivery of educational initiatives has resulted in the development of more relevant content, better performance in all of their tasks, indicating the value of this approach. Experts also suggested that networking opportunities should be given special attention because it helps in continuing education, prevents burnout and would further encourage participation.2
Support after the end of formal education maintains motivation and improves the performance of services. Education initiatives should therefore include future opportunities to meet and learn and connect young psychiatrists with their peers through initiatives such as collaborative research or interactions via an online platform.2
Working with industry to fill the gap: How can we best do it?
During the workshop, experts indicated that countries are generally open to potential educational collaborations with the pharmaceutical industry; however, there are country-specific restrictions and/or prerequisites that need to be met in order for this to work. Of interest was the fact that in a country like Thailand, the governing bodies of medical education appear to be more amenable to industry-supported education initiatives targeted at young clinicians versus trainees.2 It suggests that in some countries, there may be room for potential collaboration of professional societies and/or educational institutes with the pharmaceutical industry for education after the completion of formal training.
Furthermore, discussions underlined concerns about the ability to achieve a balanced perspective with respect to education content.2 Industry-driven educational initiatives may focus on topics that are solely ‘LEADERS’-orientated (Leader, Educator, Advocate, Diagnostician, Expert, Researcher and “Social change agent”) or disease-oriented, and not drug-focused; the remaining educational needs should be achieved through industry-independent medical education initiatives.2 This highlights significant room for potential collaborations between professional societies, educational institutes and the pharmaceutical industry for the development of initiatives centred particularly on areas such as soft skills, research and publication – noteworthy unmet needs of young psychiatrists in the region.
It is likely that useful and continuing education will best be achieved through collaborative and/or complementary initiatives from well-rounded professional societies, educational institutes and the pharmaceutical industry.2