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Chapter 1
Training in Psychiatry Today: European and US Perspectives
Martina Rojnic Kuzman,1 Kajsa B. Norstrom, 2 Stephanie Colin, 3 Clare Oakley4 and Joseph Stoklosa5
1 Department of Psychiatry, Zagreb University Hospital Centre and Zagreb School of Medicine, Zagreb, Croatia
2 Psychiatric Unit Angered, Capio Lundby Hospital, Goteborg, Sweden
3 AP-HP, Hôpital Avicenne, Service de psychopathologie de l'enfant, de l'adolescent, psychiatrie générale et addictions, Bobigny, France
4 St Andrew's Academic Centre, Institute of Psychiatry, King's College London, UK
5 Harvard Medical School, McLean Hospital, Boston, MA, USA
Introduction
The last few decades have brought rapid social changes, which have greatly influenced health, communication, ethics, politics and economics. Psychiatry, as a significant component of the health-care system, has also been affected by these changes. Nowadays, trainees and early career psychiatrists worldwide are facing several challenges, quite different from those faced previously. Young psychiatrists acquire the competencies requisite of a mental health professional through medical schools and postgraduate residency trainings, and this formative stage is crucial for the development of competent mental health professionals.
Psychiatric Training in Europe
In Europe, training programmes in psychiatry are developed and subsequently implemented by educational policy-makers, at national levels in each European country. Accreditation policy as well as quality assurance mechanisms also fall within the remit of authorities at national levels. The need for harmonized postgraduate training in psychiatry has developed in parallel with the development of the European Union. Today, the Section and Board of Psychiatry of the Union Européenne des Médecins Spécialistes (UEMS) play an active part in shaping the future of European psychiatrists. UEMS was established in 1958 as a response to the signing of the Treaty of Rome in 1957, where harmonization and mutual recognition of diplomas was foreseen.1 In 1990, the Section of Psychiatry was formed to deal primarily with general issues related to psychiatric practice and quality assurance of psychiatric care. In 1992 the Board of Psychiatry was formed, focusing on training issues. In 1993 the Treaty of Maastricht was signed on an EU level, which opened up the internal market and free movement of goods, persons, services and capital. Today, 27 European countries benefit from this Treaty, and in the last decade this has been reflected in an increasing migration of psychiatric trainees and psychiatrists across Europe.
Due to the observed huge variations in training standards, training programmes and training facilities in European countries, in 1993 the UEMS published the Charter of specialist training.2 The Section and Board of Psychiatry have drafted and approved numerous reports and guidelines to enhance the speed and recognition of the harmonization process in psychiatric training. These documents concern several areas, such as training in psychotherapy, supervision, quality assurance and accreditation of training schemes in psychiatry, and in 2009 a European framework for competencies in psychiatry was published.3 These documents are considered as guidelines and it is intended that the member countries use them in order to reform their national training programmes. UEMS has no legal authority to enforce changes in any particular country; therefore, it is important to have a continuous process of discussion and to promote a supportive attitude in order to make progress with the harmonization of psychiatric training.
Trainees' perspectives in Europe are represented by the European Federation of Psychiatric Trainees (EFPT), the first and only international organization of national psychiatric trainees' associations. EFPT has full voting rights at the European Board of Psychiatry of the UEMS, contributing significantly to the cooperation between the two organizations. The Federation has grown rapidly over the years and currently encompasses more then 30 member countries across Europe.4
As regards child and adolescent psychiatry (CAP) training in Europe, the UEMS CAP training logbook states that ‘children are not simply small adults’. Nevertheless, the core identity of child and adolescent psychiatry has been at stake for the last few decades. Whereas in most European countries CAP has slowly grown to become an independent specialty, separated from adult psychiatry, in others it is still a subspecialty or is still strongly linked with paediatrics. Hence, there are huge discrepancies in the training programmes in CAP in Europe. Within the UEMS, CAP psychiatrists used to be represented in the Section and Board of Psychiatry, until the establishment of a separate Section and Board in 1992. The ideas behind this initiative to split within the UEMS were to promote high standards of mental health care for children across Europe, both directly and indirectly, by establishing standards and improving the quality of postgraduate CAP training, with a particularly strong emphasis on training in psychotherapy.5
Again, the perspective of European CAP trainees is represented by the EFPT, which now provides a valuable framework for European child and adolescent psychiatry trainees to discuss and exchange ideas. Its inner structure has recently been modified in response to the growing identity claims of CAP trainees, as a new board position for a ‘CAP secretary’ was created, allowing specific representation of CAP trainees in European CAP meetings, and enhanced links with international organizations, such as UEMS-CAP and the European Society for Child and Adolescent Psychiatrists (ESCAP).
Psychiatric Training in the USA
The young psychiatrist training and practising in the USA today faces a different set of challenges than the psychiatrist training just a few decades ago. The structure of psychiatric training itself has shifted from a participation-based into a competency-based model, in response to pressures from government, practitioners and patients to make physicians more accountable to the public. Psychiatric training is regulated by a single governing body for all US residencies, which is a private, non-profit council called the Accreditation Council for Graduate Medical Education (ACGME). The ACGME was established in 1981 from demands in the academic medical community for an independent crediting association with the mission to ‘improve health care by assessing and advancing the quality of resident physicians' education through exemplary accreditation’.6 Comprising 28 specialty-specific Residency Review Committees (RRCs), each RRC is formed by 6–15 volunteer physicians appointed by the American Medical Association (AMA) and individual specialty boards. It is these RRCs that then determine the specific programme requirements for each specialty training programme, including psychiatry. RRCs also have direct oversight on each specific training programme institution to ensure sufficient support within each programme. Each residency training programme submits to a review by its RRC at least every 5 years. During review, each programme provides extensive information on all aspects of training, which is then verified by the site visit to solicit trainee and faculty feedback, and make direct observations on patient care, staff and facilities.7
In 1959, child and adolescent psychiatry was established as an official subspecialty of general psychiatry. Residents wishing to pursue this subspecialty can enter the two-year fellowship after either their third or fourth year of general psychiatry training. The core requirements of child and adolescent specialty training also fall under the purview of the psychiatry RRC.
Around this system of regulation, several unique situations in US culture have evolved that sculpt the modern psychiatry resident's experiences, including the rise of core competency-driven education, the advent of national duty hours regulations, and the US health-care system of managed care.
State of the Art of Psychiatric Training in Europe
For the majority of European countries, curricula for psychiatric training across Europe are set by national authorities. In a significant proportion of European countries, the curricula are developed in accordance with the UEMS requirements for the specialty of psychiatry and standards, as defined in the document called the ‘Charter on training of medical specialists in the EU: requirements for the specialty of psychiatry’.2 A selection of the UEMS recommendations is given in Table 1.1.
Table 1.1 A selection of requirements for the specialty of psychiatry according to charter on training of medical specialists in the EU released by the Union Européenne des Médecins Spécialistes (UEMS)2
| CENTRAL MONITORING AUTHORITY FOR PSYCHIATRY (defines the requirements for the monitoring Authority, the recognition of teachers and training Institutions, quality assurance mechanisms and recognition of quality) |
| GENERAL ASPECTS OF TRAINING IN PSYCHIATRY (in addition, it defines the selection and access to the training, the circumstances of the interruption of training, training abroad and funding) | Training duration The minimum duration of training will be 5 years in psychiatry; can take place in different institutions if they are recognized nationally as training institutions; part-time training should be possible in every EU member state Definition of common trunk Within the national training programme in psychiatry there is a common trunk of fundamental knowledge and skills that is required of all candidates. The common trunk is compulsory. This common trunk includes training in inpatient psychiatry (short, medium and long stay), outpatient psychiatry (community psychiatry, day-hospital), liaison and consultation psychiatry, and emergency psychiatry. Psychotherapy training is also part of the common trunk. Training should cover general adult psychiatry, old age psychiatry, psychiatric aspects of substance misuse, developmental psychiatry (child and adolescent psychiatry, learning difficulties and mental handicap) and forensic psychiatry. The training programme can include not more than one year of flexible training (e.g. research or other related subjects to be approved by the head of training) Practical training Practical training should evolve around routine clinical work under supervision. As training progresses there should be an increasing level of responsibility. During the period of training rotation within different sections of an institution should be compulsory. Rotation to different institutions should be facilitated |
| Supervision Clinical supervision should be available on a daily basis. In addition to clinical supervision and psychotherapy supervision, individual educational supervision (dealing with such subjects as attitude, growth in the profession, etc.) is compulsory for a minimum of 1 hour per week, at least 40 weeks per year Implementation of training programme/training logbook The theoretical and practical training will follow an established programme approved by the national authorities in accordance with national rules and EU legislation as well as with the requirements and recommendations of the European Board of Psychiatry. The different stages and the activities of training and the activities of trainees should be recorded in a training logbook APPENDIX 1: Theoretical training Training should include a structured training (lectures, seminars, etc.) over 4 years, on average for 4 hours per week. The subjects to be covered are the scientific basis of psychiatry, psychopathology, examination of a psychiatric patient, diagnosis and classification, psychological tests and laboratory investigations, specific disorders and syndromes, child and adolescent psychiatry, mental handicap, psychiatric aspects of substance misuse, old age psychiatry, diversity in psychiatry, legal, ethical and human rights issues in psychiatry, psychotherapies, psychopharmacology and other biological treatments, multidimensional clinical management, community psychiatry, social psychiatric interventions, research methodology, epidemiology of mental disorders, psychiatric aspects of public health and prevention, medical informatics and telemedicine, leadership, administration, management, economics |
| APPENDIX 2: Training in psychotherapy Psychotherapy is an integral part of training in psychiatry. The content that is considered essential for training in psychotherapy include a mandatory part of the training curriculum that takes place within working hours, practical application of psychotherapy in a defined number of cases, theory of psychotherapy over at least 120 hours, supervision provided on a regular basis for at least 100 hours, individual (at least 50 hours) but preferably also group supervision. Experience should be gained with a broad range of diagnostic categories, including assessment and evaluation of outcome. Experience in psychotherapy should be gained with individuals as well as families and groups. As a minimum, psychodynamic, cognitive behavioural therapy (CBT), and systemic theory and methods should be applied, but integrative psychotherapies are highly recommended. Personal therapeutic experience/feedback on personal style is highly recommended. Research methodology should be included Training should if possible take place within different parts of mental health services. Supervisors should be qualified. Training should be publicly funded |
| REQUIREMENTS FOR TRAINING INSTITUTIONS (defines the criteria for the recognition of training institutions, their size and the quality assurance of training institutions... |
