An Outline of training for FCPS in Psychiatry (3rd and 4th Yr)

An Outline of Structured Training Programme (STP) for FCPS in Psychiatry (3rd and 4th Year of Training)

Movadat H Rana,Saeed Farooq,Muhammad Iqbal Afridi

Source: http://www.jpps.com.pk/display_articles.asp?d=239&p=art

INTRODUCTION 

The College of Physicians and Surgeons Paki­stan (CPSP) for the first time started propagating the process of setting up of formal structured training programmes in the late 1990’s. This was supported by workshops on Structured Training Programmes (STP) for the trainers organized by the Department of Medical education of CPSP in various disciplines. The most re­cent step in this regard was the CPSP’s announcement of a residency programme to further formalize and struc­ture the training for Fellowship in various disciplines1. 

The Faculty of Psychiatry of CPSP produced the first document in this regard in 2007, which was ac­cepted by the Department of Medical Education of CPSP as a model STP. The detailed booklet presenting the STP for FCPS Intermediate Module, published by CPSP, is now available in print2. The broad parameters that inspired the document published by CPSP, similar to that for Intermediate Module, are presented in this paper for reflection, critique and raising debate on this im­portant issue and welcome any suggestions and com­ments. 

A typical structured training programme encom­passes a preparation period with defined entry require­ments, predetermined objectives based on a curriculum defined by an authoritative body, with assessments and feedback to the trainee and an exit from training defined by a certificate of completion of training1,3. All STPs are inspired by a one or another learning philosophy, that range from the traditional model to behavioural and modern approaches based on the cognitive approach. 

The STP developed by the Faculty of Psychiatry of CPSP seeks its inspiration from the cognitive and constructivist approaches to learning. An experiential learning strategy is emphasized by this STP4. A heavy emphasis is laid on the significance of attitudes and ethical practices and inculcation of professionalism5. This is in addition to the already existing importance attached to the domains of knowledge and psychomotor skills in account of the unique demands of the field of mental health. Although the importance of skills in undertaking quality research amongst trainees in all disciplines is established6, 7 but it has been given special significance in this STP. 

This is the second part of the structured training programme (STP) based on the 3rd and 4th years training leading to FCPS psychiatry (Part 1, published in J Pak Psych Soc 2008;5:58-64). The document encourages the residents to undertake learning and teaching oppor­tunities amongst each other and also to learn by facili­tating other members of the mental health team i.e. nurs­ing staff, social workers and psychologists. For the first time, portfolios on each resident’s representative work are recommended as an important formative assess­ment tool to help trainees to record their achievements. These portfolios are expected to be maintained mutu­ally by the residents as well as the supervisors. A spe­cial effort has been made to introduce assessment tools (formative and summative), to assess all the three learn­ing domains i.e. knowledge, skills and attitudes, that fulfil all the criteria of a good examination. In view of the unique demands of the profession, an extra competency level ‘ability to teach and critically evaluate’ has been added. The last two levels of competency will be emphasised in particular in this phase of the training.

Structured Training Programme (STP): 

FCPS in Psychiatry 

Structured Training Programme (STP) includes learning objectives (knowledge, skills and attitudes), es­sential learning experience, competence levels ex­pected, syllabus and assessment techniques for exam­ining at the CPSP. The aims of STP for FCPS in Psychia­try are as following:1, 2 

1. To provide a standardized model for structuring training at different centres. 

2. To outline the learning objectives of training in aspects of knowledge, skills and attitude. 

3. To provide a competency based core curriculum and suggest preferred learning modalities. 

4. To describe the minimum requirements for eligi­bility to appear in the CPSP examination for FCPS in Psychiatry. 

5. To describe the processes of training and monitor the performance of trainees and thus regulate training opportunities at approved centres. 

6. To describe tools of assessment (both internal and external) so that candidates could work and pre­pare for the final assessment by the College. 

SPECIFIC LEARNING OBJECTIVES

At the end of the FCPS Psychiatry, the candidates should be able to acquire the following attributes in the three domains of learning: 

1. KNOWLEDGE 

a. Formulate a diagnostic and management plan using medical, neurological, anthropo­logical, psychological and social aspects of psychiatric disorders 

b. Critically evaluate and discuss contempo­rary issues in psychiatry 

c. Undertake appropriate assessment and management in the fields of adult, child, ge­riatric, organic, and liaison psychiatry 

d. Adequately use the knowledge about the cross cultural aspects of psychiatry in his/ her interactions with patients 

e. Appropriately use pharmacological, physi­cal and non-pharmacological methods of treatment 

f. Appropriate use of articles of the Mental Health Act 2001 in forming forensic opin­ions 

g. Formulate plans to respond to major mental health challenges faced by the community 

2. SKILLS 

Written Communication Skills: 

a. Make a diagnostic formulation of a patient. 

b. Update medical records in clear, concise and accurate manner 

c. Formulate forensic assessments in the light of the relevant rules and instructions of Men­tal Health Act 2001. 

d. Demonstrate competence in medical writ­ing 

Interpersonal Communication Skills: 

a. Establish professional relationships with patients and their relatives and or caregivers in order to obtain a history, conduct a physi­cal examination and provide appropriate management 

b. Demonstrate use of appropriate language and clear communication in seminars, bed­side sessions, out patients, e-communica­tion and other work situations 

c. Demonstrate competence in presentation skills in clinical, academic and professional settings 

d. Demonstrate the skills and art of effective communication with patients in therapeutic and professional interactions. 

Examination Skills: 

a. Demonstrate the skills of effectively and smoothly carrying out the detailed physical, neurological and psychiatric examination and detect presence or absence of neuro­logical, physical and psychpathological signs. 

b. Interpret general physical, systemic and mental state examinations to formulate di­agnosis, differential diagnosis and manage­ment strategies. 

Patient Management Skills:

a. Interpret and integrate the history and ex­amination findings and arrive at an appro­priate differential diagnosis and final diag­nosis.

  

b. Demonstrate competence in problem iden­tification, analysis and management of the problem at hand by the use of appropriate resources, and interpretation of investiga­tion results.

  

c. Prioritize clinical problems for the start of in­terventions.

  

d. Use evidence-based pharmacologic and psychosocial interventions.

  

e. Able to formulate and execute management of complex cases with multisystem disorders. 

f. Independently conduct supportive psycho­therapy, group therapy, behaviour therapy and other evidence based psychotherapies or psychotherapeutic interventions. 

g.Able to independently use and teach elec­troconvulsive therapy and other physical / biological therapeutic interventions.  

Skills in Research: 

a. Undertake literature search and collect evi­dence based database and standard guide­lines for use in clinical practice and re­search. 

b. Compile, interpret and discuss a research and write a dissertation / an article based on original research in a peer reviewed jour­nal, in light of the instructions on the subject by CPSP. 

c. Interpret and use results of various research articles to improve clinical practice and re­search. 

Administrative and Managerial Skills 

a. Practice administrative and managerial skills in running a psychiatry unit 

b. Organize educational, training and research activities 

c. Able to carry out a departmental audit 

3. ATTITUDES 

Towards Patients: 

a. Establish a therapeutic relationship with all patients 

b. Demonstrate commitment to the bio-psycho­social model in the assessment and man­agement of the patients 

c. Demonstrate sensitivity, empathy and understanding while performing physical and mental state examination.

d.  Consistently show consideration of the in­terests of the patient and the community para­mount and always above personal interest  

e.  Adhere to principles of medical ethics in general and mental health ethics in particu­lar.  

f.  Exhibit highest standards of professional­ism and adherence to the core values of the  medical profession, through the practice of integrity, respect for patients, colleagues, seniors and juniors, compassion, honour, altruism, excellence and humanism.  

g.  Demonstrate ability to work as a team mem­ber as well as a leader . 

Towards Self Development: 

a. Demonstrate consistent respect for every human being irrespective of ethnic back­ground, culture, socioeconomic status and religion. 

b. Deal with patients in a non discriminatory and prejudice free manner. 

c. Deal with patients with honesty, equity and compassion. 

d. Demonstrate flexibility and willingness to adjust appropriately to changing circum­stances. 

e. Foster the habit and principles of self edu­cation and reflection in order to constantly update and refresh knowledge and skills and as a commitment to continuing education. 

f. Recognize stress in self and others. 

g. Deal with stress and support medical col­leagues and allied health workers. 

h. Handle self criticism or criticism by col­leagues or patients constructively. 

i. Obtain and value a second opinion on clini­cal matters. 

j. Demonstrate effectiveness as member of the team, as well as a leader 

Towards Society: 

a. Exhibit sensitivity towards the social, ethical and legal aspects of health care provision. 

b. Offer cost effective professional services. 

c. Make earnest efforts to remove myths and misconceptions and stigma against the men­tally ill prevailing in the society. 

ESSENTIAL LEARNING EXPERIENCES 

The residency programme should include learn­ing exercises and opportunities leading to the ability to organize family intervention sessions and small group therapy sessions, use statistical packages such as SPSS for Windows to compile data and interpret it, critically evaluate scientific articles in the journals, practice ad­ministrative and managerial skills required to run an indoor and outdoor psychiatric facility, undertake a stan­dard medical audit and complete and submit Disserta­tion to RTMC at CPSP before the end of 3rd year / submit articles for publication. 

COMPETENCE LEVEL EXPECTED OF A TRAINEE IN PSYCHIATRY FOR 3^RD  AND 4^TH  YEAR OF FCPS 

A candidate is expected to attain the laid down level of competence by the end of each specified period as defined in table 1:

SYLLABUS 

1. Child and Adolescent Psychiatry: Normal devel­opment of child, Classification of childhood Psy­chiatric Disorders, Psychiatric assessment of chil­dren, Pervasive developmental disorders, Hyper-kinetic disorders, Conduct disorders, Anxiety dis­order, Disorders of elimination, Mental sub-nor­mality and Child abuse. 

2. Geriatric Psychiatry: Psychological issues of ag­ing, Mood disorders in elderly, Anxiety disorders in elderly, Psychotic disorders in elderly, Abuse and neglect of elderly, Neuropsychiatric disorders, Primary and secondary pre-senile and senile dementias, Organization of community services for elderly and Rehabilitation. 

3. Forensic Psychiatry: Mental health Act, Adminis­trative Management of Psychiatric cases, Forensic Psychiatric Syndromes, Psychiatrists’ role in court, Management of violence and risk assessment, Psychiatric report and Ter­rorism. 

4. Public Mental Health (Community Psychiatry) including knowledge and skills of organising and evaluating a community mental health programme and knowledge of the National Programme of Mental Health in Pakistan. 

5. Normal Human Sexuality and Sexual & Gender Identity Disorders

6. Personality disorders

7.  Psychological factors affecting medical conditions: History, classification, and current trends, Gastrointestinal disorders, Obesity, Car­diovascular disorders, Respiratory disorders, En­docrine and metabolic disorders, Psycho-cutane­ous disorders, Stress, infectious diseases and psy­chiatry, Behaviour and immunity and Psycho-on­cology. 

8. Additional conditions that may be focus of attention: Treatment compliance, Adult anti­social behaviour and criminality and Border­line intellectual functioning and academic prob­lems. 

9. Special areas of study: Addictionology, Psychia­try and reproductive health, Genetic counselling, Death, dying and bereavement and Psycho-trauma 

10.Psychotherapies: Evaluation for psychotherapy, Combined pharmacotherapy and psychotherapy, Supportive Therapy, Group therapy, Family therapy, Marital therapy, Interpersonal psycho­therapy, Cognitive therapy and Behavior therapy. 

ASSESSMENT 

This STP recommends a system of internal assessment by the training institution using a forma­tive approach and a summative assessment or­ganised by the College at the end of the training period. 

1. INTERNAL ASSESSMENT BY THE TRAINING INSTITUTION 

The formative methods that are recommended for use as part of the internal assessment organised by the training institution are: 

a. Portfolio-Based Assessment 

Supervisor and the resident are recommended to jointly maintain a portfolio containing the training programs, weekly work schedule and the follow­ing documents: 

• Specimen Formulations and Management Plans developed by Trainee 

• Internal Assessment results 

• Presentations made in journal clubs and seminars 

• Salient features of feedback sessions by consultant / supervisor on histories, formu­lations and psychotherapy sessions 

• Salient features of feedback sessions on in­ternal assessment performance 

• Clinical audit reports 

• Ongoing assessment record particularly of attitudes and scores on professionalism pa­rameters. 

b. Written and Clinical 

Local training institutes should conduct Six-monthly or Annual assessments on the pattern of FCPS exams to give practice to the trainees . 

A suggested format is as follows: 

• Written (33%) Paper 1: MCQs: One best type and Extended Matching Type Paper 2: 10 SEQs 

• Clinicals (34%) One Long Case, Three Short Cases (Psychiatry, Medicine, Neurology), Structured Viva / TOACS OR OSCE 

• Attitude: Professionalism: (33%) 

c. Feedback Sessions 

Detailed feedback sessions for the residents may be regularly organised. These may be based on their ongoing clinical performance, attitudes, and performance in the quarterly or six monthly as­sessments. These sessions should also include a feedback by the resident on the supervisor as well as the training institution. Reflections of the trainee as well as the supervisors in these sessions are recommended to be formalised and recorded. Where ever feasible 360 degree ap­praisal system may be put into place to ensure a comprehensive and a structured all-inclusive feed­back. 

d. Assessment of Attitudes and Professional Char­acter Development 

This system of assessment of ethics and attitudes is a continuation of the process initiated at the start of the FCPS training on induction into the STP. As during the Intermediate Module all train­ees must once again be communicated the impor­tance and significance of this aspect of training. A total of 33% marks in the internal assessment may be allocated to this domain. Any student showing deterioration or inability to come up to the required standards must be counselled adequately by his/ her supervisor and a record of the same placed in the portfolio. An Inability to improve or change in the behaviour or attitude over the next 12 weeks may be communicated to the Head of the Depart­ment, local tutor, and or the RTMC of CPSP (Table 2). 

DISSERTATION: Every FCPS Part 2 trainee should sub­mit a certificate of approval of dissertation / publication of articles, based on original research by Research & Training Monitoring Cell (RTMC). 

ASSESSMENT BY CPSP: 

Written: Paper 1 and 2 comprising of Ten SEQs. 

Clinicals: One Long Case and Fifteen Task Oriented Assessment of Clinical Skills (TOACS) Stations. 

Table of Specification 

The table of specifications for the final examination will consist of the following: 

WRITTEN: 

Paper 1: Ten Short Essay Questions: Adult Psychiatry, Child and Adolescent Psychiatry and Psychogeriatrics 

Paper 2: Ten Short Essay Questions: Liaison Psychia­try, Organic Psychiatry, Public Mental Health, Psychogeriatrics, Forensic Psychiatry, Therapeutics in­cluding Psychotherapies, Addictionology / Substance abuse, Eating Disorders, Psychosexual Disorders, Re­productive Health, Psychotrauma. 

CLINICALS: 

One Long Case: Clinical interview and assessment of a complex psychiatric management issue, its formulation, followed by a discussion on diagnosis, management, prognosis and modern guidelines, and recent advances 

on the issue.  

Fifteen TOACS stations: Interactive stations (Observed):  Eight 

Non-interactive Stations (Unobserved):  Seven  

Proposed Table of Specification for TOACS: 

Observed Stations: 

Station 1: Outdoor Assessment Skills: Adult Psy­chiatry 

Station 2: Making a Liaison Psychiatric Assessment / Decision-making 

Station 3: Emergency Assessment / Intervention: Adult Psychiatry 

Station 4: Communication / Teaching Skills 

Station 5: Public Mental Health / Administrative / Management/Organisational Skills 

Station 6: Use of a Non Pharmacological Interven­tion /Physical Method of Treatment 

Station 7: Neurological/ Medical Assessment and Management / Decision making 

Station 8: Child and Adolescent Psychiatry / Psychogeriatrics 

Unobserved Stations: 

Station 9: Psychotherapy 

Station 10: Psychometric/ Radiological / Laboratory / Electrophysiological Investigations 

Station 11: A diagnostic dilemma 

Station 12: Interpretation / Critique of a Published Research Article 

Station 13: Use of Standardised Guidelines / Evidence –based Medicine 

Station 14: Therapeutics Station 15: Forensic Assessment / Specialised areas in psychiatry 

CONCLUSION 

As mentioned earlier the details of the STP are now available at the CPSP. However, an outline is pre­sented in this paper for reflection, critique and raising debate on this important issue. Traditionally, relatively little attention is paid to the laying down of measurable objectives of training programme and defining modali­ties of matching assessments methods. In a developing country like Pakistan it is even more difficult in view of the limitations posed by feasibility and resource con­straints. The College of Physicians and Surgeons has always taken a lead in overcoming these constraints by playing a pioneering role in developing a clear vision in organizing its training programmes. The STP prepared by the faculty of Psychiatry is a testimony to the same approach. The newly launched Residency Programme of CPSP based on similar STPs shows the College’s will and commitment to improve the training and as­sessment methods in the country and make them the envy of institutions in the West. The document on STP in Psychiatry is presented here to welcome any sugges­tions and comments to improve the training experience of the trainees further and seek guidance from the men­tal health fraternity to develop the training process fur­ther. 

REFERENCES 

1. Rana MH, Farooq S, Ali S, Afridi MI. An Outline of Struc­tured Training Programme(STP) for FCPS in Psychiatry (Intermediate Module). J Pak Psych Soc 2008;5:58-64. 

2. College of Physicians and Surgeons. Structured Train­ing programme for FCPS Psychiatry: Intermediate Mod­ule. College of Physicians and Surgeons Karachi, Paki­stan; April 2008. 

3. Trainee Forum. What is structured training? [Online] 1997 [Cited on 2008 October 01] Available from: URL: 

http://cancerweb.ncl.ac.uk/cancerweb/ trainees/ doc/ structur.html. 

4. Bruning RH, Schrow G, Ronning R. Cognitive psychol­ogy and instruction. 2nd ed. New York: Prentice-Hall, 1995. 

5. Elton L. Strategies to enhance student motivation: a con­ceptual analysis. Studies in Higher Educ 1996; 21:57-68. 

6. Bassaw B, Roff S, McAleer S, Roopnarinesingh S, DeLisle J, Teelucksingh S, et al. Student’s perspective on the educational environment, Faculty of Medical Sciences, Trinidad. Medical Teacher 2003; 25: 522-6. 

7. Owen D, House A, Worrall A. Research by trainees. A strategy to Improve standards of education and super­vision. Psychiatric Bull 1995; 19: 337-40. 

ABSTRACT 

This is the second part of a series of documents outlining structured training programme (STP) for Fellowship in Psychiatry of College of Physicians and Surgeons, Pakistan. This outline focuses on 3rd and 4th year of residency. It has been prepared to facilitate the FCPS postgraduate trainees as well as their trainers in making the training and the process of assessment standardised, consistent, and trans­parent. The unique emphasis in this STP on internal assessment, through the use of innovative and high fidelity, valid, and reliable tools such as portfolios, extended matching and one best type MCQs, and OSCEs is highlighted. A renewed emphasis on ethics and inculcation of professionalism through a process of active feedback and reflection during training is the key feature of the document. A proposed list of important topics based on current trends in psychiatry that need to be covered in the knowledge domain, with a list of competencies and skills that are to be acquired during training is included. The STP is being presented with an aim to receive feedback from trainees, trainers and mental health profession­als on the document. 

Key words: Structured Training Programme (STP), College of Physicians and Surgeons Pakistan (CPSP), Psychiatry.