Students’ Perspectives of Competency-based Medical Education in Undergraduate Psychiatry Clinical Training: A Qualitative Evaluation

Study Design and Setting

This qualitative study was conducted in the Department of Psychiatry in a tertiary care teaching hospital in South India. The hospital has 1300 beds, including 60 inpatient Psychiatry beds. It caters to the urban underprivileged population. When the study was conducted, the Department of Psychiatry had 13 psychiatrists, three clinical psychologists, and three psychiatric social work consultants. Ethical clearance was obtained from the Institutional Ethics Committee (IEC number 147/2021).

Research Team

All authors in this study worked as teaching faculty from the same setting with MD Psychiatry or DNB Psychiatry or PhD in Clinical Psychology. All of them were female except author 4, a male Psychiatrist. All the authors were part of the department’s Undergraduate Committee. They were involved in implementing the UG CBME Psychiatry Curriculum in the medical college from 2021. The corresponding author was part of the “Indian Psychiatric Society UG education Subcommittee” for drafting guidelines for the CBME manual for UG Psychiatry training. ²² The authors were interested in the perspectives of stakeholders of CBME, that is, students. Before the study started, the authors assumed that students would have more exposure to clinics and hands-on training in clinical postings in psychiatry with the CBME curriculum. All the authors have taken UG classes for the current second professional batch during the clinical posting. All the authors are well-versed in conducting qualitative studies.

Participant Recruitment

There is an annual intake of 150 medical students. The UG medical students of the second professional year were divided into eight batches comprising 18–20 students, each in a schedule predetermined by the Department of Medical Education. According to the National Medical Council-Competency-Based Undergraduate Curriculum document, these batches of students attended the first clinical posting in Psychiatry. ⁵

Inclusion criteria: UG medical students in their second professional year attending their first clinical posting in Psychiatry from July 2021 to November 2021.

Exclusion criteria: Students with <50% attendance in the clinical posting. Eighty-three students attended the clinical posting in psychiatry during the study period. On their first day of posting, students were informed that they were the main beneficiaries of CBME, and hence, the authors wanted to know their perspectives on the CBME curriculum.

We recruited students after written informed consent. Sixty-seven consented to participate, and one refused to participate. Fifteen students were absent on the first day of the posting and, therefore, needed to be enrolled. Consecutive sampling was used. We mentioned that end-of-posting marks will not be affected if they choose not to be part of the study. We assigned an alphanumeric code to each participant. The data were anonymized by removing all identifiers. The study was conducted according to Helsinki’s declaration.

Data Analysis

Thematic analysis was used to analyze the data according to the method described by Braun and Clark. ²⁴ The data corpus, consisting of written responses to the semi-structured questionnaire, were analyzed manually in its entirety, forming the data set. A deductive approach consisted of predefined themes of the perceived impact of UG posting on knowledge, skills, and attitude, barriers to learning, and suggestions to improve the posting. This was in line with Braun and Clarke’s suggestions. ²⁴ The first and second authors coded the data separately. Then, the first and second authors independently searched for subthemes, reviewed them, and defined and named the subthemes. All the authors jointly produced the report after discussion. Differences in structure and nomenclature of the subthemes were resolved by reaching a consensus through discussion among all the authors. Artificial Intelligence tools were not used in the data collection or analysis.

Perceived Impact of the Posting

Students expressed a sense of increased knowledge in treating patients presenting with distress and unexplained physical symptoms. This is a welcome change in light of past research showing suboptimal skills in primary care physicians dealing with similar patients. ²⁶ Students opined that Psychiatry was a “logical branch” and an active field of medicine. This could be due to students witnessing various techniques used by the consultants to elicit various signs of mental status examination (MSE). This contrasts with other studies from India where students perceived psychiatry as not precise and unscientific.^19,27 Students in our study reported learning clinical aspects beyond diagnosis and treatment. The Department of Psychiatry at All India Institute of Medical Sciences, Rishikesh, has developed a model for UG Psychiatry training comprising neurobiology, lumping and splitting of disorders, formulation of short-term plans, clinical interpretation of lab reports, and is thus not limited to diagnosis and treatment. ²⁸ This model was developed on the premise of the NMC document, which aimed to make the Indian Medical Graduate (IMG) a physician, scientist, administrator, and policy maker. ²⁸ Our students understood that mental illness needs medical treatment like any other medical condition. Others have shown similar results. For example, the curriculum of Monash University provides as much importance to training students about psychiatric illnesses as other medical disorders. ²⁹

Students in our study felt that stigma toward psychiatry was unnecessary. Correspondingly, fear of psychiatry was reduced among students, and confidence increased in dealing with psychiatry patients. Students reported to have understood the importance of mental health. We infer that students in this study had favorable attitudes toward psychiatry. Other studies have shown mixed results. A study on the impact of psychiatry training done on first and second-year students showed negative attitudes toward psychiatry and psychiatric illnesses. ³⁰ However, a qualitative study noted that the type of UG Psychiatry teaching, exposure to Psychiatry during clinics, and charismatic teachers as role models were some of the reasons for choosing psychiatry for post-graduation. ³¹

This was supported by another study that suggested clinical exposure during psychiatry postings could change students’ perspectives on patient care and clinical practice and minimize stigma toward psychiatry and psychiatric patients. ¹⁶ These discrepant findings could be related to differences in settings, the level of available resources, and training received by teachers of Psychiatry. Manohari et al. recommend that teachers actively inculcate interest and remove stigma toward psychiatry. ³² Concerning students, attitude changes could occur in association with the use of strategies like elective postings, mentorship programs, and direct clinical assessment of patients by students.^33,34

Study participants expressed that the clinical posting helped them learn interaction/communication skills, particularly in psychiatry. This is in keeping with the agenda of CBME to produce IMG with good communication skills. ¹¹ Students also report “improved skills in the doctor-patient relationship.” IMG needs skills in developing doctor-patient relationships. ²⁷ This helps in dealing with difficult or uncooperative patients in any branch of medicine. ⁴ Our students realized the importance of dealing with patients with empathy, which follows Attitude, Ethics, and Communication (AETCOM) principles. ³⁵

Barriers to Learning During Posting

Students in our study expressed many barriers. Difficulties in assessing uncooperative patients and “loud” patients have been reported. The recommended strategies to overcome the barriers include simulation techniques and videos of agitated and uncooperative patients in the clinical classes. ³³ Students reported a need for more trust by patients in students’ doctors. This is concerning as CBME has introduced the student doctor method of learning. It is thus important to address this. It should also be considered that traditional T-L methods are tough to employ in subjects like psychiatry. ³³ This could be due to a need for more trust in student doctors, patient’s perspective of their therapeutic alliance with students, and patients’ discomfort with their presence in therapy sessions. Some strategies to address this could be the distribution of students across the teaching faculty, consultant-guided demonstration during patient interaction, and reduction in several student doctors in the therapist room.

Students in this study report barriers due to their inadequate expertise in asking sensitive questions; this has been shown even in postgraduate Psychiatry residents. ³⁶ This perceived barrier could be overcome by consultants demonstrating how they handle sensitive issues of patients during outpatient clinics in the presence of a limited number of students. Students also reported challenges from external factors, like difficulty in assessing the reliability of history from informants. The posting timing and the patient’s language match the student’s language, which can be managed with prior planning. Barriers to learning, such as logistic issues and lack of interest in didactic teaching, were reported by the non-CBME batch. ²¹ Students have reported that the need for more effort in history taking is a deterrent to learning. Teachers could reflect that effort in history taking by students is expected to be a “process” of skillset development rather than an outcome. This may address the barrier reported by students.

Feedback on Training to Improve the Clinical Posting in Psychiatry

Students’ feedback was to emphasize clinical practice over theory. A study from South India examining first-year MBBS students’ perspectives highlighted the need for clinical exposure early in their careers. ³⁷ Students emphasized that small group teaching should be implemented among the TL methods. ³⁸ In a study about innovative teaching methods as discussed by students, patient-based clinical teaching and guided demonstration with patients have been perceived as useful by students. ³⁹ So, case-based teaching is a suggested strategy to enhance learning in Psychiatry. ⁴⁰ UG students will benefit from close professional relationships with consultants and senior residents for a positive teaching experience and attitude shift.^33,41

Students in our study sought an increase in the duration of Psychiatry posting. Current CBME focuses on stipulated time for completion of specific skill sets. ¹¹ The Original context of CBME was to give students time flexibility so they can complete skills at their own pace. ⁴² Another suggestion from students was for classes to focus on primary care. This is in keeping with the need for primary care physicians to identify and treat common mental health issues. ⁴ These reflect the cornerstone of CBME, which emphasizes skill-based learning over knowledge. ⁵ Students have suggested a specific focus on teaching history, taking in “different situations” and “asking specific questions” according to different situations. This reflects that students have been exposed to real-world case scenarios in the Psychiatry ward. Demonstration classes can include co-operative and non-cooperative patient assessment and special populations like elderly and young mothers and patients with medical co-morbidities. Skill-building sessions can be focused on eliciting effect and thought and asking sensitive/specific questions.

Strengths of the study

Students are the stakeholders, and this study discusses student perspectives on the CBME curriculum. This is one of the few qualitative studies on students’ perspectives on the CBME curriculum in UG Psychiatry clinical posting in India. Qualitative studies provide depth of information about students’ perspectives. The availability of students’ perspectives on CBME and non-CBME curricula may help in the future to compare the benefits of both curriculums.

Limitations

The findings are not generalizable to government colleges or resource-limited settings. However, similar questions in settings with resource constraints can be beneficial in ascertaining the associated themes that emerge. A formal quantitative assessment of change in stigma toward Psychiatric disorders was not measured. This is the qualitative reporting of students. We have yet to receive feedback from faculty or patients whom students interviewed.