POSTGRADUATE MEDICAL EDUCATION COURSE

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POSTGRADUATE MEDICAL EDUCATION IN PSYCHIATRY FOR FAMILY PHYSICIANS
Ijaz Haider

INTRODUCTION

Psychiatric Disorders are prevalent at all ages in Pakistan and in 32 years of my practice as Psychiatrist I have seen almost 5000 patients per year of Psychiatric disorders in my hospital as well as in private practice. It is important to remember that Brain is an important part of our body responsible for our behaviour. Behaviour can be understood, learnt and managed by the individual. If brain is not functioning properly then cognitive and behavioural disturbances take place, however these changes are also influenced by sensitivity of individual’s personality, environmental factors and precipitating factors.
What are Psychiatric Disorders? In our daily life many life events take place which bring changes in neurotransmitter system and emotional responses in person, these may be present as restlessness, tension, aggression, anxiety, depression and behavioural changes and under different circumstances a person expresses different behaviour which may not be long lasting yet affects our mental health and may present as abnormal reaction.
Psychiatric illnesses are divided into Psychotic disorders, Anxiety disorders, Somatoform disorders, Epilepsy, Drug addiction, Organic brain disorders and behavioural disturbances.
The main cause of these psychiatric disorders are neurochemical changes in body and brain and which are expressed in various forms depending on intensity of the chemical changes.

Many factors play an important part in the development of an adult which include genetic component, childhood experiences, home atmosphere and finally environmental and precipitating factors in life .

Aim of the Course of Postgraduate Training in Psychiatry at Ijaz Psychiatric Institute, Lahore.
1. To make/trainees familiar with established knowledge in the main areas of clinical psychiatry.
2. To provide some understanding of the biological and behavioural sciences related to psychiatry, and of the relevance of developments in these subjects to clinical problems.
3. To give students some familiarity with a variety of different conceptual approaches to and explanatory theories of the phenomena of psychiatric illness.
4. To inculcate a critical approach both to explanatory theories and to establish clinical customs, to provide an understanding of the scientific method and the nature of scientific hypotheses, and to encourage trainee to put these principles into practice in the course of their clinical work.
5. To enable students to use library efficiently and economically, and to give them some experience of presenting theoretical and clinical material to their colleagues and other professional audiences.
6. To give those with specialized interests the opportunity to develop themselves both with academic knowledge, and clinical experience within the context of this broadly based training.

The Course includes important Psychiatric topics such as Clinical Examination, Schizophrenic Disorders, Mood Disorders, Child Psychiatry, Adolescent Problems, Organic Mental Syndromes, Substance Use Disorders, Anxiety Disorder, Somatoform Disorders, Sexual Issues, Eating Disorders, Personality Disorders and Psychiatric Emergencies.

Special attention have been paid to topics of Medical diseases and viral infections, Neurological disorders and problems of women in this course.

A brief description of Behavioural Sciences has been included and number of hours for each topic have also been spelled out. The objectives of the course have been specified. Panel of teachers is quite experienced and each student will be tested for his command on the subject after it has been taught and an evaluated paper will be returned to the concerned candidate.

In medical colleges the undergraduate training programme includes only few lectures and demonstrations by the department of Psychiatry which are grossly insufficient to any doctor especially if he is inclined to go into general practice.

In family practice it has been found that 30-40% of patients have psychiatric symptomatology and are reluctant to consult psychiatrist as they feel that symptoms are organic related (somatic) and not psychiatric. This may become chronic, debilitating due to lack of adequate training and handling of illness.

Since Psychiatry and Dermatology questions are in one paper, students fail to understand the importance of psychiatric disorders and therefore do not pay much importance to the subjects, to lectures, papers and examination of psychiatry.

It is admitted that in the past there were only 05 major psychiatric disorders but DSM IV (Diagnostic and Statistical Manual of Mental Disorder 4th Edition) published by the American Psychiatric Association Washington D.C. in May, 1994 has given 290 to 335 and ICD-10 (International Classification of Diseases-10th Edition) has given F00 to F99 disorders.

The subject of Behavioural Sciences has gained some importance in the curriculum of M.B.B.S. and thereafter have been included in some detail in the D.P.M. & N Course. It includes:-

1. Application of Behavioural Sciences in health and disease.
2. The biopsychosocial model in medical practice.
3. Basic principles Behavioural Sciences applied to medical practice.
4. Individual attributes such as memory, learning and conditioning, emotions, stress etc. and
5. Biological influences

Research in the application of Behavioural Sciences to medical practice has also been included in the DPM & N course.

Various topics after consultation with the faculty have been given some hourly distribution as follows:

TABLE - I Month – 1 Interview Methods , Alcoholism and Drug Addiction , Affective Disorders , Descriptive Psychopathology , The Role of the clinical Psychologist , The Electroencephalogram, (37 hours)
Month – 2
Basic Issues in Psychiatry, Anxiety Disorders, Schizophrenia, Abnormal Personality, Abreaction, Hypnosis, Rehabilitation Methods. (40 hours)
Month – 3
Group Psychotherapy , Social Psychology, Individual Psychotherapy, Basic Issues in Psychiatry (cont.), Interview Methods (Cont.), (28 hours)
Month – 4
Behavioural Approaches in Psychiatry, Introduction to Research Methods, Psychiatry and Genetics, Biochemistry, Mental Handicap, Psychiatric Administration, (43 hours)
Month – 5
Clinical Pharmacology and Neuropharmacology, Measurement in Psychiatry, Sleep and its Disorders, Suicide and Parasuicide, Social & Community Evils, Clinical Neurology, Eating Disorders. (58 hours)
Month – 6
General Hospital Psychiatry, Hospital and Community Psychiatry, Marital Psychtheray. (19 hours)
Month – 7
Geriatric Psychiatry, Forensic Psychiatry, Sexual Disorders. (20 hours)
Month – 8
Child and Adolescent Psychiatry. (20 hours)
Month – 9
Forensic Psychiatry (Cont.) Revision of Previous Courses. (26 hours)
Total: 291 hours

The Postgraduate Training Course in Psychiatry at IPI has also selected topics for SEMINAR/ DISCUSSION AND JOURNAL CLUB which will be held each Saturday. Some of the topics are as follows:-

1. Schizophrenias. 2. Affective disorders and Personality disorders. 3. Neuroses/Psychosomatic Disorder. 4. Organic Psychiatry & Psychiatric Investigation. 5. General Medicine Related to Psychiatry. 6. Forensic Psychiatry & Drug Dependence. 7. Child Psychiatry & Mental Retardation. 8. Neurology & Community Psychiatry. 9. Treatment is Psychiatry. 10. Genetics related to Psychiatry & unusual Psychiatric Syndromes. 11. Psychopathology. 12. Liaison Psychiatry Social Transcultural Psychiatry.

The curricula for D.P.M. & N Course both for Part I and II have been laid down as follows:-

CURRICULUM D.P.M. & N PART – I at the end of 130 hours
1. Neuro Anatomy
2. Neuro Physiology
3. Behavioural Sciences
4. Psychology.

CURRICULUM D.P.M. & N PART – II at the completion of 161 hours

PAPER I: Neurology, Child Psychiatry, Forensic psychiatry; Mental Subnormality; General Medicine.

PART – II: General Clinical Psychiatry

PRACTICAL: VIVA, LONG CASE and SHORT CASE

DISCUSSION

Good Practice in our clinical relationships “Vulnerable patients, Vulnerable doctors” has been published by Royal College of Psychiatrists in 2002 and the following 20 – key issues summarized in the current report are included in this D.P.M. & N Course as follows.

1. It is the management’s responsibility to make sure that their doctors have the time and resources to perform their work satisfactorily. Doctors should not compromise what they can safely achieve by case-load.
2. Where doctors work in multi-disciplinary teams or in liaison with other services, remits should be made clear and lines of responsibility laid down.
3. It is the doctor’s possibility to ensure that he/she keeps up to date through a peer-reviewed personal development plan. It is the management’s responsibility to carry out a regular appraisal of the doctor’s work.
4. The doctor should work towards the empowerment of the patient and his/her carers in decisions about immediate treatment and the planning of longer-term care.
5. To that end, consent should be sought wherever possible and carefully recorded. The autonomy of the patient should be overridden only when he/she clearly lacks capacity and it is in the patient’s best interests, for as short a time as possible, and in the least restrictive way compatible with the patient’s safety, other than when the patient is subject to mental health legislation. When determining a patient’s best interest, relatives and carers should be consulted whenever practicable.
6. Particular safeguards should be taken in the care of especially vulnerable groups such as children, the elderly and those patients with learning disabilities. Agreed procedures should be strictly adhered to.
7. Patient empowerment is assisted by information given in a clear and sensitive manner, repeated as necessary, in private surroundings. Only rarely will be doctor have the right to decide that it is in the patient’s interests to withhold specific information at a specific time.
8. The doctor should be sensitive to the culture of the patient and the interpretation that might be placed on even the most routine of medical practices, Experienced interpreters should be sought wherever language is a problem.
9. Doctors should avoid seeing patients alone in isolated circumstances such as deserted out-patient clinics out of hours. Home visits should be carefully prepared, agreed to, carried out accompanied where practicable, and the dangers anticipated.
10. It is the doctor’s responsibility to preserve the confidentiality of any relationship with a patient. The limits to that confidentiality, such as legal procedures and team-working, must be clearly explained.
11. Within that confidentiality, the need for carers to know enough to support the patient properly must be respected. The doctor should facilitate the right of the patient to a trained advocate.
12. Contemporaneous notes should be taken of all formal interviews with patients and the confidentiality of those notes protected. Confidentiality must not be jeopardized by the passage of information within and between services.
13. However senior the doctor, objective advice should be sought indifferent circumstances. All trainees must be carefully supervised in their work.
14. Doctors may be called upon to perform many different roles for their patients. These roles, and the rules governing them, must not be confused.
15. Physical contact may be perceived as an appropriate comfort in some situations and as an assault in others. What matters is the meaning of the doctor’s behaviour for the patient, not the innocence of the doctor’s intentions.
16. Relationships of sexual intimacy between doctor and patient are totally unacceptable. Both patient and doctor will be protected by the use of chaperones where misinterpretation is possible.
17. Innovative techniques should be used only if there is good evidence as to their propriety and effectiveness, with the consent of the patient and with full preparation.
18. Self-disclosure is a skill that should be used rarely, in the interests of the patient not those of the doctor.
19. Doctors should not stand in the way of the patient’s right to a second opinion. Complaints procedures should be clearly advertised and explained.
20. It is the doctor’s duty to tackle peers about any practices they deem unacceptable and to inform their management accordingly. It is the management’s responsibility to protect a doctor in the exercise of that duty.

RESULTS
WEEKLY TIME-TABLE/SCHEDULE

All trainee-family physicians will be taken in IPI as part time, students after they have fulfilled their entry criteria. During first 03 months they concentrate on basic subjects – Neuroanatomy, Neurophysiology, Psychology, Neurochemistry, Psychopharmacology, Genetics & Statistics. Each fifty percent time will be spent in basic subject whereas remaining 50% time they learn and practice clinical psychiatry Community Psychiatry, Forensic Psychiatry, attend journal club and attend O.P.D. once a week.

During next 4-6th months they will be taught research methodology, given clinical project, to write clinical case histories, go to library for using library facilities and evaluation test is given each Saturday for 1.1/2 hour from the course they have covered in previous weeks. Their papers will be checked and returned back to them after suggestions to improve. Final evaluation will be based on a proforma approved by the Dean, & submitted every 4 monthly. This proforma will contain details of attendance, written, clinical presentation, test-given & taken, projects, Punctuality, conduct and any special comments by the co-ordinator of the course.

During the 2nd half of the year training programme they will be attached to each Consultant of Psychiatry/Neurology/Child Psychiatry/Medicine and in 4 weeks, where they will learn the approaches of treatment by all senior Psychiatrists of the Deptt. Of Psychiatry, participates in O.P.D., ward work, writes histories, presents cases to the consultant and takes active part in the management of psychiatric patients of all categories.

There will be a regular seminar held each week in which topics allotted to various students will be displayed well in advance on the notice Board and will be discussed by the professor. They will also be explained the difficult topics either by the teacher with interest or by the visiting professor from Peshawar, Karachi & Rawalpindi. Each trainee psychiatrist will also learn to write a paper on a topic of their interest under the guidance of Supervisor which will be presented at a forum of Psychiatric interest to give him confidence and art of presentation.

OPINION OF PSYCHIATRY AMONG GENERAL PRACTITIONERS

Fifty-four General Practitioners & Family Physicians of Lahore city were sent a general questionnaire regarding imparting of Psychiatric training to them.

Forty one responded. Majority appreciated the idea that Family Physicians should be provided with an opportunity to get proper, organized postgraduate training in Psychiatry to enable them to deal with Psychiatric patients more appropriately.

More than two-third expressed that training programme must not coincide with their practice hours and hence suggested that afternoon lectures and case demonstration would be more useful for General Practitioners and more doctors will benefit from afternoon classes.

Seventy percent of the respondents were of the opinion that each General Practitioner to be inducted for IPI Psychiatric Postgraduate Programme must have at least 05 years experience in general practice.

Two third expressed the view that Psychiatric Postgraduate trainings for family physicians must be an open programme in which they should be allowed to attend 2 or 3 lectures per day and be allowed to spend more time in completing requisite hours of training in Psychiatry rather than it should be fixed for the period of some months or one year at a stretch as regular programme.

Keeping in view these positive responses Ijaz Psychiatric Institute has planned to open up a Diploma in Psychiatry (D.P.M. & N) Course for G.Ps. and Family Physicians from April, 2005. Those who are interested may register with the IPI by 28th March, 2005.

REFERENCE:
1. Mubashar, M. H.’ Herrbert M. Behavioural Sciences, A Report of the National Workshop on Behavioural Sciences in Pakistan Organised by WHO Collaborating Centre for Mental Research and Training, Rawalpindi Medical College, Rawalpindi, Nov. 2 – 4, 1991,

2. Saeed, K.,Iqbal, Z., & Mubbashar, M.H. Teacher Training Manual, Institute of Psychiatry, WHO Collaborating Centre for Mental Health, Rawalpindi General Hospital, Rawalpindi; 1994.

3. Scully, J.H., Bechtold, D.H., Bell, J.A., Dubovsky, S.L., Neligh, G.L. & Petersen, J.L., 2nd Edition Psychiatry, The National Medical Series for Independent Study, 1990.

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Ijaz Clinic
5- Race Course Road,
Opposite Circuit House, Lahore, - Pakistan.
Phones : 6304923, 5720730 Fax : 7586440
email : ijazhaider15@hotmail.com email : soniaijaz@yahoo.co.uk