| Abstract|| |
The significance of mental health in the entire health scenario has increased. However, the representation of psychiatry in the current MBBS curriculum for undergraduate students in India still remains much less than desirable. Further, stigmatising attitudes lessen these future doctors' ability to detect and manage patients with psychological problems despite adequate knowledge about psychiatry. Students believe that psychiatrically ill patients are unpredictable and can be dangerous to others. Some feel that psychiatry is unscientific, imprecise and treatment is not effective. Traditional teaching methods are directed more towards imparting knowledge than changing the attitudes of students. Newer teaching and assessment techniques should be used to bring about attitudinal changes and develop interest among medical students. Case based and problem based learning, small group teaching, simulated patients, using movies, multidisciplinary seminars, integrated teaching, attitude questionnaires, objective structured clinical examinations etc., could be introduced in the curriculum to achieve this objective.
Keywords: Attitudes; Curriculum; Medical students; Psychiatry; Teaching
Peer reviewer for this paper: Anon
| Introduction|| |
Over the last few decades, there has been an exponential growth in psychiatric services all over India. We now have about 4000 outpatient facilities, 10,000 beds in teaching hospitals and >40 mental hospitals. There are now about 0.3 psychiatrists per 100,000 population in the country (Mental Health Atlas More Details, WHO, 2011).  Though this is far below the desired doctor - patient ratio of 1 psychiatrist per 100,000 population, it does show a healthy rising trend. Under the National Mental Health Programme, funds are being provided to develop existing psychiatry departments of medical colleges and increase the number of trained mental health professionals. Funds have also been disbursed to start new courses in psychiatry (Sinha and Kaur, 2011).  One of the most recent developments is the setting up of mental health help-lines in various parts of the country. This shows that not only the average person but also those in power recognise the significance of psychiatry in the total health scenario. Increasingly, the local, state and central governments are allocating greater funds towards revamping and starting newer services in psychiatry. However it still remains the Cinderella that receives step-motherly and step-sisterly treatment in the medical field, especially in areas of allocation of space and funds. Even the representation for psychiatry in the current MBBS curriculum for undergraduate students is meagre. One of the primary reasons for this is preconceived notions and attitudes among doctors about mental health and disorders. Some of them are present before they enter the medical college and are similar to those present in the general population. Others come up in the college itself by observing the reactions of the non-psychiatric faculty and staff (Ndetei, Khasakhala and Ongecha-Owuor et al., 2008;  Baxter, Singh and Standen et al., 2001).  These 'students' are going to be the face of the medical fraternity in the future, as well as medical administrators, policy makers and advisors in medical colleges, on health bodies, medical bodies etc. They will be treating and referring our patients, allocating funds and infrastructure, developing curricula for medical colleges, giving recognition to degrees and diplomas. They will be the first point of contact for most psychiatry patients. However the undergraduate medical training is not adequate as many cases are missed. Physicians and surgeons would be able to identify, treat and refer their patients with comorbid emotional disorders only if adequate training in clinical skills is included in the curriculum. This training can also be used to improve the communication skills and attitudes of the doctors resulting in a better doctor patient relationship.
General epidemiological surveys in India have found 20-50% of patients attend primary care services primarily for mental health problems (Patel, 1999).  Mental health care must be available at the primary care level; only then can we cater to the burden of mental illnesses and mental health problems. Basic mental health services can then be managed in primary health care services resulting in considerable cost savings without detrimental effects on health. The skills that are learned in psychiatry are important for all doctors: For example, the ability to form relationships with a patient, to assess the mental state and to impart distressing information. Hence adequate training of psychiatry is necessary at the undergraduate level itself. In addition to acquiring knowledge regarding the biological, psychological, sociological and humanistic aspects of the practice of medicine, the goal of undergraduate psychiatric education should also be to assist the student master basic interpersonal skills and develop informed attitudes based on current psychiatric knowledge relevant to the management of patients with emotional illness.
Similar sentiments on medical education have been echoed throughout the world, that objective attitude is highly important while teaching psychiatry to medical students (Kelly, Raphael and Byrne, 1991).  Stigmatising attitudes lessen the future doctors' ability to detect and manage patients with psychological problems despite adequate knowledge about psychiatry (Malhi, Parker and Parker et al., 2003). 
Several studies have been carried out to identify negative attitudes. Recent data (Lingeswaran, 2010)  suggests that students do believe that psychiatrically ill patients can be dangerous to others, that they are unpredictable, react inappropriately and are hard to talk to. They have themselves to blame and need to pull themselves together. Some do feel that psychiatry is unscientific, imprecise and treatment is not effective while others feel that psychiatrists abuse their legal powers. As a branch some do find it non-lucrative. Older perceptions about black magic etc., do not really exist today, which is heartening. But observing relapses and readmissions may in fact result in last year students showing more negative attitudes as compared to 1 st year.
Some studies have shown that psychiatric postings do change some of the attitudes of medical students, though many studies do not replicate this (Gulati, Das and Chavan, 2014,  Konwar, Pardal and Prakash et al., 2012,  Amini, Moghaddam and Nejatisafa et al. 2013,  Lyons, 2014,  Fischel, Manna and Krivoy et al., 2008).  Traditional teaching methods are directed more towards imparting knowledge. However changing the attitudes of students do not form part of the main learning objective of this teaching.
| Current Undergraduate Training in Psychiatry|| |
The current undergraduate training in psychiatric illnesses consists of didactic lectures, clinical postings (small group teaching, case presentations) and internship (supervised case management). The subject is part of the medicine examination with questions being optional in the undergraduate assessment. As the subject is not mandatory, students tend to be indifferent (Reddy, 2007).  Recent literature on psychiatric education (Kallivayalil, 2012  ) suggests that newer teaching techniques should be used to achieve the objective of bringing about attitudinal change and developing interest among medical students. Other desirable objectives like doctor - patient relationship (see also this issue pgs 83-91), communication skills, professionalism and ethics have also been found to be effectively achieved through these methods.
Problem based learning (PBL) is a commonly used newer teaching technique (Wood, 2003).  PBL teaching consists of modules based around a problem (e.g., a patient with delusion). The session can be half a day, with an introduction and also probably a video, based around the theme. The students can then be divided in groups and given problems related to the theme. Facilitators guide the groups, students then make a presentation on the questions raised about the problem and how they arrived at answers. Presentations are interactive. Then, a facilitator gives a summary and take home message. Students are given time for private study where they can read, see patients and work on case presentations.
Other techniques which have been very effective are case-based learning, small group teaching, micro-lectures, small group work with tasks, focused group discussions, creating buzz groups (which are groups of 2 or 3 given a specific task and short time to discuss and present to larger group). Role-playing using actors, simulated patients (McNaughton, Ravitz and Wadell et al., 2008),  prepared video recordings using movies, case vignettes etc., can also be useful.
In a 2001 study (McNeilly and Wengel, 2001  ) they used clips from popular serial ER to teach how patients with emotional problems can present and how difficult they are to handle, the resistance they show etc. Practical teaching exercises, physician - patient communication can be carried out. Another very effective approach is use of multidisciplinary seminars and integrated teaching especially on topics like pain, dyspnoea, chest pain, abdominal problems, fatigue, reproductive disorders, ageing etc., (Gleason and Fritz, 2009).  In a Sri Lankan study (Rodrigo, Wijesinghe and Kuruppuarachchi, 2012),  a professorial 8 weeks' clerkship in the final year where they are exposed to acute inpatients, child patients and patients undergoing de-addiction was found very effective. In our case, we could apply these during internship. The assessment should also include attitudinal aspects. Objective structured clinical examinations can be used to assess the interpersonal and communication skills (O'Sullivan, Chao and Russell et al., 2008).  Attitude questionnaires can be used to assess their opinions about psychiatry patients and psychiatry (Konwar, Pardal and Prakash et al., 2012,  Fischel, Manna and Krivoy et al., 2008). 
Thus the undergraduate curriculum should be modified so that students acquire attitudes like empathy, learn to respect patients and understand their feelings, develop therapeutic relations and sensitivity about stigma, recognize the value of psychiatry as a medical discipline, learn the importance of a multidisciplinary approach, and are able to understand their own attitudes and how it affects patient care (Murthy and Khandelwal, 2007). 
| Concluding Remarks (Figure 1: Flowchart of Paper)|| |
Medical students' attitude towards psychiatry can influence their ability to diagnose and treat patients with psychiatric symptoms. As a result, these patients may not be identified especially in a primary care setting. The undergraduate curriculum must be modified so that students can develop good interpersonal and communication skills. They should also be able to develop the attitudes of empathy, compassion, respect etc., while treating patients.[Figure 1]
As traditional teaching methods are more focused on improving the knowledge and clinical skills in psychiatry, newer teaching technologies should be introduced to improve attitudes and interpersonal skills. They can also increase students' interest in the subject and decrease the stigma towards psychiatry. Student-centred teaching methods like PBL, small group teaching, integrated teaching etc., can be used to improve student satisfaction and develop the right attitudes to psychiatry and psychiatrically ill patients.
| Take Home Message|| |
The medical curriculum should be modified using newer teaching technologies to develop the attitudes of empathy, respect, understanding, etc., and to reduce the stigma towards psychiatry resulting in better patient care.
Conflict of interest
This is my original unpublished piece not under consideration for publication elsewhere.
| Questions that this Paper Raises|| |
- How do we reduce the stigma related to psychiatry among medical students?
- What changes are needed in the curriculum to achieve this?
- Will the faculty and students accept the newer teaching methods?
- Will the newer teaching methods be able to decrease the negative attitudes?
- Does changing attitudes result in better patient care?
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| Authors|| |
Ajita Nayak MD is currently Professor and Head of Unit at the Department of Psychiatry, Seth G. S. Medical College and KEM Hospital,
Mumbai, India. She has completed a Fellowship in medical education under the Foundation for Advancement of International Medical Education and Research (FAIMER). She is a postgraduate guide and examiner in Psychiatry. She has carried out many research projects that have won awards at the local and regional conferences. She has published articles in national and international journals on child and adolescent psychiatry, schizophrenia, music therapy, geriatric psychiatry, etc. She has conducted many projects with medical students which have received ICMR scholarships. She is a faculty for various MCI recognised faculty development courses in medical education. She has been an investigator for several multinational drug trials.