Year : 2016 | Volume
: 21 | Issue : 2 | Page : 88--90
Psychiatry as a separate subject in the undergraduate medical curriculum: The need re-emphasized
Rajesh Sagar, Siddharth Sarkar
Department of Psychiatry and National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
|How to cite this article:|
Sagar R, Sarkar S. Psychiatry as a separate subject in the undergraduate medical curriculum: The need re-emphasized.J Mental Health Hum Behav 2016;21:88-90
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Sagar R, Sarkar S. Psychiatry as a separate subject in the undergraduate medical curriculum: The need re-emphasized. J Mental Health Hum Behav [serial online] 2016 [cited 2022 Aug 11 ];21:88-90
Available from: https://www.jmhhb.org/text.asp?2016/21/2/88/193425
Psychiatry has yet to be given due prominence in undergraduate medical curriculum in India. At present, in the undergraduate Bachelor of Medicine and Bachelor of Surgery (MBBS) curriculum, psychiatry is allocated 20 hours of lectures, optional clinical posting before the final professional examination, and 2 weeks of clinical posting during internship. The evaluation of theoretical knowledge of psychiatry is done as a part of a paper in medicine. The emphasis on psychiatry as a specialty in medical curriculum is woefully low as compared to some of the Western countries. While 8 weeks of clinical postings are mandated for psychiatry in the United States (equivalent in duration with Obstetrics and Pediatrics there), a full-time psychiatry clerkship for 3 months is recommended in Great Britain. Closer home, Sri Lanka, Nepal, and Malaysia have a greater duration of psychiatric clinical rotation than earmarked for the Indian medical colleges. Thus, psychiatric training and exposure have received lesser attention as compared to other countries, and as compared to some of the other disciplines in India.
Concern about the need for emphasis on psychiatric education is not new. Even in the 1960's, psychiatrists had felt the need for focusing on teaching of psychiatry in the undergraduate medical course.  Since then, many eminent scholars and stalwarts in psychiatry have advocated that psychiatric curriculum be strengthened in the undergraduate medical teaching, and psychiatry may be considered as a specialty which is examined separately (like pediatrics and obstetrics). ,,
The Ministry of Health and Family Welfare (MoH and FW) and Directorate General of Health Services for a long time have been aware of the need. In this regard, in a meeting of Central Mental Health Authority (CMHA), on February 26, 2008, it was proposed to strengthen the psychiatry in MBBS curriculum. It was suggested to introduce psychiatry as a compulsory subject. This was followed by the meeting on October 16, 2008 of various heads of Departments of Medicine and Psychiatry of Medical Colleges of Delhi, in the Directorate General of Health Services, MoH, and FW. In this meeting, the need to strengthen psychiatry in the undergraduate curriculum was clearly highlighted. It was suggested to make psychiatry as a compulsory and independent subject for examination and to make psychiatry as compulsory posting during internship period. This point was further emphasized in subsequent meetings of CMHA. There have been constant efforts for appropriate push and advocacy to Medical Council of India (MCI) and National Human Right Commission as well. A submission made by the Psychiatric Education Committee of the Indian Psychiatric Society also outlined a detailed course content for psychiatry and listed the common things a medical student should be able to do at the primary health-care level.  Although an impressive list of recommendations have been made by the MCI like increasing the teaching hours allocated for psychiatry, making psychiatry posting mandatory during internship, being taught in an integrated manner with community medicine, increasing the marks allocated during final assessment, and internal assessment being made mandatory for final assessment, implementation remains a challenge.  Moreover, the primary suggestion for setting apart psychiatry as a separate subject for undergraduate summative assessment is yet to be approved.
The call for psychiatry as a separate subject for assessment in the undergraduate medical curriculum has several pragmatic reasons. First, this will increase the trained personnel competent to manage common mental health issues. Psychiatric disorders are important causes of morbidity in the general population.  The shortage of trained workforce in the form of psychiatrists is a concern in India. Much of the caseload of psychiatric disorders can be handled by the primary care physicians, and only selected cases need referral to a specialist. Thus, training the medical graduates about psychiatric disorders would empower them to deal adequately with psychiatric morbidity in the community and provide competent psychiatric care. It has been seen that clinical posting in psychiatry has been associated with an increase in knowledge about psychiatric disorders and improved attitude toward patients with mental illnesses.  Thus, improved training of medical graduates would help to extend the provision of psychiatric care to a larger population and provide communities with the first line of mental health care providers at close quarters.
Second, training about psychiatric disorders and behavioral problems would help clinicians in dealing with patients from other specialties as well. Clinicians are likely to encounter a few "difficult" patients in whatever specialty they practice. Training in psychiatry encompasses communication skills as a major component. Most often, the reason of doctor-patient conflict is miscommunication between the doctor and the patient. Adequate clinical exposure in psychiatry, as well as theoretical component of behavioral sciences, may help a clinician in his/her formative years to learn about skills of conflict avoidance and/or conflict resolution.
Third, psychiatric disorders being common disorders in the community, it is likely that medical professionals in any specialty would encounter patients who had comorbid psychiatric disorders or are receiving psychotropic medications. Adequate clinical experience during undergraduate training may help them to recognize the symptoms of flare-up of a psychiatric disorder, and understand the implication and interaction of the psychotropic medications that the patient might have been receiving. In addition, some patients may have behavioral manifestations of the medical illness (e.g., delirium due to hyponatremia, or depression associated with systemic lupus erythematosus). Adequate psychiatric training may help clinicians to recognize psychiatric manifestations of medical illnesses and take appropriate actions. Thus, exposure to psychosomatic medicine or consultation-liaison psychiatry would be of help to medical graduates for their future careers in other specialties as well.
Fourth, stigma and misconceptions about psychiatric disorders still continue to prevail not only in the community but among medical professionals as well.  Proper structured training in psychiatry of all medical graduates would help to ameliorate inaccurate information about mental illnesses and may reduce the stigma toward the mentally ill. Since members of the society place doctors' views in high regard, these changes in attitudes are likely to trickle down to the other members of the society as well. Thus, adequate training in psychiatry as a specialty would be beneficial in terms of reduction of stigma. In addition, this would also provide an opportunity to a physician who is himself/herself distressed to know when and where to seek help, as it has been seen that undergraduate medical students themselves are reluctant to seek mental health care. 
Fifth, presently, the government is attempting to train medical officers from each of the districts in the basics of psychiatry. Such trainings are of short durations and impede on the general working schedule of the medical personnel at their center. Moreover, the yield of training over a couple of weeks may not sustain over time. Thus, enhancing the duration and intensity of psychiatric teaching in the undergraduate curriculum would minimize the need for such training at a later stage, and reduce the need for expending resources on short term training.
Sixth, patients with suicide attempts and depression, are encountered commonly by several other specialties. Suicides are an important cause of death in the young population and needs sensitization of clinicians for timely referral. Moreover, many physicians and surgeons are called in for care of patients with suicidal attempts to manage the emergency. Appropriate evaluation of individuals is important after medical/surgical stabilization of the individual to prevent recurrence of suicidal attempt. Hence, training during the undergraduate medical course may help clinicians for synergistic psychiatric management of patients with recent suicide attempts.
The above reasons highlight the advantages that are to be gained by expanding the training of psychiatry among the medical graduates in India. The point still remains of what would be the best approach. Designating psychiatry as a separate subject which is assessed independently in the MBBS final examinations would probably a move in right direction. This would stimulate the students to take this subject more seriously as they would have to pass an examination separately. This would also encourage them to participate more thoroughly during the clinical rotations, as they would be judged on their clinical performance in the final practical examinations. In sync, a separate rotation in psychiatry would also need to be carved out when the students would get structured and guided clinical exposure. The optimum duration for such a posting would be 8-10 weeks, and would potentially include case-based discussions, demonstrations of interview techniques, bedside rounds, detailed bio-psycho-social assessments of patients, simulated cases, observation of electro-convulsive therapy, and feedback on their own interview techniques. This would also provide an opportunity to reinforce that psychiatric disorders may improve with effective treatment by demonstrating individuals who have improved with psychiatric care. Furthermore, psychiatrists as teachers would have to make teaching and learning of psychiatry effective and interesting for the students.  It would require firm commitment from the psychiatrists to engage in teaching of undergraduate students and impart basic skills to them consistently.
The benefits of designating psychiatry as a separate subject are manifold. Yet, it would require sensitization of governing bodies, representation to them from various psychiatric societies, and proactive dialogue with other specialties so that they can see the merits of psychiatric education in their clinical work. Hopefully, we would see acceptance and implementation of psychiatry as a specialized subject in India in times to come. We would need to prepare model curricula for students, , so that undergraduate students' exposure in psychiatry is focused and enriching. Furthermore, we would need to be open to constant updating of the content, process, and methods of teaching as more experience is gained with time.
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