A New Tool for Teaching Psychopharmacology

Everyone would probably agree that the practice of clinical psychiatry has changed profoundly over the second half of the past century. One of the most remarkable changes has been the rapid development and expansion of clinical psychopharmacology, which has become, like it or not, a dominant part of the clinical practice of most psychiatrists. Available treatments for mental disorders changed and our armamentarium broadened. We have numerous medications for psychiatric disorders. We even use medications for disorders traditionally considered only amenable to and suitable for psychotherapy. Clinical psychopharmacology, after its growing pains, has become a full-fledged, complicated discipline. New medications appear all the time that have various, at times complicated and serious, adverse-effect profiles. Drug-drug interactions have become an important issue. Clinical studies comparing psychotropic medications and reports on their benefits or dangers appear each month in psychiatric journals. The evidence base of clinical psychopharmacology keeps growing at an amazing rate. Pharmacoeconomics is already changing our practice, and new pharmacogenetic technologies seem to be on the verge of changing it even more. How to teach clinical psychopharmacology The knowledge base of clinical psychopharmacology is clearly growing and becoming increasingly complex. It is obvious that because of information overload, any one person's expertise in all aspects of clinical psychopharmacology has to be decreasing. Nevertheless, clinical psychiatrists need to be educated and skilled in all aspects of clinical psychopharmacology. Thus, because of the growing complexity of psychopharmacology there is a need for creating some kind of "collective expertise and wisdom" by the experts in the field, which needs to be taught to physicians by using innovative teaching methods. As Glick and colleagues noted, "psychopharmacology was taught using an apprenticeship model, with trainees expected to learn about medications by shadowing their mentors, reading in libraries, and applying that knowledge to the cases they saw."1 While using the apprenticeship model in clinical psychopharmacology may be practical and useful, this educational practice cannot embrace all the intricacies and complexities of the field. Furthermore, this model raises the important issue of whether the mentors themselves are keeping up with the developments in the field and, if so, how they do it. The "amount of material needing to be taught has expanded, [while] the resources available to do the job have contracted."1 The 2 traditional sources of information for clinicians and experts, journals and psychopharmacology textbooks, have their own strengths and weaknesses. The number of journal articles and the complexity of their interpretation are increasing. Publication bias may be difficult to untangle at times. Textbooks usually bring a huge, comprehensive volume of information that may be somewhat difficult to digest, and they may be somewhat outdated because of the publication delay of books. Thus, there is a great need for a summary of information that: • Is generated by experts. • Is up-to-date. • Is comprehensive yet relatively easy to understand. • Is easy to use for teaching purposes by those who may not be experts in every aspect of the field. • Is easy to update, revise, and adapt to local needs ("portable"). • Uses new technologies. • Is unbiased and not influenced by the pharmaceutical industry. Model curriculum These criteria certainly represent an ideal that may be difficult to achieve completely. The information provided in such a format would be enormously helpful to teachers in psychiatry residency training programs, physicians in the field, teachers of medical students, and possibly physicians in other fields and disciplines. Some persons may argue that some of the distributed newsletters and digests (free or not-so-free of charge) fulfill at least some of the criteria. Perhaps they do, however, we believe that the best teaching tool or format that would fulfill all these criteria is a model psychopharmacology curriculum. As Goldberg2 has pointed out, model curricula have a checkered history in psychiatric education. They have a static feel to them and can make otherwise seasoned educators feel like substitute teachers. Yet, the ideas behind them are compelling. In addition to the expertise, comprehensiveness, and easy understanding that such a curriciulum would provide, a model curriculum could be used at multiple sites and levels and could provide standardized educational materials across the field throughout the country. American Society of Clinical Psychopharmacology curriculum About a decade ago, the curriculum committee of the American Society of Clinical Psychopharmacology (ASCP) developed the first edition of its model psychopharmacology curriculum.3,4 This curriculum was developed from an earlier version of a psychopharmacology curriculum prepared in the early 1980s under the auspices of the American College of Neuropsychopharmacology (ACNP).1,5 The ACNP curriculum, although well received and translated into several languages, has never become widely used.1 The newer ASCP version has undergone several revisions during the past decade (the fifth revision is under way). It has outgrown its originally relatively primitive format (eg, slides available only as printed hard copy) and has become fairly sophisticated. In a small survey following the distribution of its first edition, 62% of the responders from the training programs surveyed found that the ASCP curriculum was, to varying degrees, satisfying, and it improved their psychopharmacology teaching.3 The results of this survey and other feedback have been used in the development of the subsequent editions of the model curriculum. The ASCP model psychopharmacology curriculum consists of lectures by experts in the field, selected by the members of the ASCP Curriculum Committee (for the fourth edition: Drs Glick, Balon, Ellison, Janowsky, Lydiard, Oesterheld, Osser, Thompson, Walton, and Zisook). The contributors were asked to provide the committee with an expert lecture on a certain topic (eg, a well-known expert on the psychopharmacology of generalized anxiety disorder is asked for her or his lecture on that topic). They were also given some specifications regarding the format of the lectures (eg, pretest and posttest questions, major teaching points, outline, length, and making sure that the slides are free of bias). It is important to note that the initial version of the curriculum was supported by an unrestricted grant from Eli Lilly to cover the administrative costs, although Lilly did not influence the content. However, the newer editions of the curriculum were developed without any outside support-committee members gave their time voluntarily and without any compensation, and the administrative costs were covered by the ASCP (partially by the sale of the curriculum to residency programs). We have to emphasize that the existence of the model curriculum would not be possible without the incredible generosity of the psychopharmacology experts around the country who donated their lectures (either lectures in existence or newly created lectures) and their time in creating, refining, and revising them. Curriculum description and content The key issue seems to be providing psychopharmacology teachers with a core group of slides that can be used to present the lecture as it stands or from which each local teacher can build a lecture.3 Thus, the main part of the curriculum consists of slides of 60-plus lectures by experts in their field. However, lectures alone would not be enough for comprehensive teaching. Therefore, the curriculum (fourth edition) consists of 3 printed spiral-bound volumes that, in addition to hard copies of all slides, include various materials important for teaching psychopharmacology. The slides of all the lectures also are provided on a CD in PowerPoint format. The curriculum consists of 3 volumes (Table).Goldberg2 stressed that clinical education is best developed when conceptualized as sequential and linked to the rest of the teaching program; thus, all the lecture modules are organized as follows. • The "crash course" is presented first. This is to be used in PGY-1 and PGY-2 because it stresses the basics of inpatient and emergency department psychiatry and emphasizes safety and drug-drug interactions. • The next module includes a PGY-2 basic or introductory course. • The following module includes the PGY-3 and PGY-4 advanced psychopharmacology course. • Finally, child and adolescent psychopharmacology and geriatric psychopharmacology courses are included. The complete list of lecture topics is beyond the scope of this article, but the curriculum covers psychopharmacology of all mental disorders for which evidence exists. Lectures on topics such as evidence-based psychopharmacology; combining psycho pharmacology and psychotherapy; electroconvulsive therapy; other biological therapies; and drug-drug interactions are included. How to use the ASCP curriculum As the instructions for the model curriculum note, this curriculum should not be considered a textbook or handbook of psychopharmacology. It is not a reference book. It is a sophisticated teaching tool that provides a clinically oriented overview of the field aimed at teachers, residency directors, and others responsible for physician education and for ensuring standards of knowledge and practice (competencies) within an organization. Because of its flexibility, the persons using the curriculum can add, delete, change, reorder, or combine slides from different modules and build their own lectures based on the chosen slides. Hard copies of the slides (included in Volumes 2 and 3) may be distributed to the audience to allow note writing. Some lectures consist of "key" slides marked by asterisks and slides considered to be "extra," which allows the lecturer to use either the "key" slides by themselves or the entire lecture series, depending on time availability. The lectures do not usually provide references; rather, the user is referred to the recommended list of journals and texts for the appropriate text, chapter, or article. Each lecture includes a pretest and posttest that may be useful to gauge the effectiveness of the teaching. Because the ASCP Curriculum Committee recognized the difficulties in introducing such a curriculum and the anxieties associated with it, names and contact information of its members are provided in case consultation is needed or users wish to provide feedback or to suggest improvements. Usefulness of the curriculum beyond residency training The ASCP curriculum is intended primarily for teaching clinical psycho-pharmacology in residency training programs and fellowships (child and adolescent, and geriatric). However, the expert-based knowledge, comprehensiveness of the program, and that the curriculum is regularly and frequently updated may suit physicians in the field who would like to update their knowledge base and skills (especially if they are unable to attend the many continuing medical education programs around the country or if they would like to avoid industry-sponsored educational activities). Future of the curriculum The future of any curriculum depends on its use by educators in the field. Because we believe the model psychopharmacology curriculum meets most if not all the criteria for a modern educational tool, we hope that more and more residency training programs in psychiatry will use the curriculum in their programs. We believe that each program should identify, if possible, a coordinator or director of psychopharmacology training who can introduce and implement this curriculum. The curriculum will be regularly and frequently updated, and we hope to continue to use experts in the field to provide top-notch psychopharmacology education to our trainees. The ASCP Curriculum Committee is planning to include another subspecialty track on the psychopharmacology of substance abuse disorders (in addition to the child/adolescent and geriatric psychopharmacology tracks) in the curriculum. Other ideas entertained as part of the curriculum expansion include possible developments of psychopharmacology curricula for medical students and primary care physicians, or making parts or modules of the curriculum available to interested physicians. We hope that the ASCP model psychopharmacology curriculum will help improve the quality of clinical psychopharmacology education, and that it will ultimately benefit our patients. References: References 1. Glick ID, Zisook S, Shader RI. The challenge of teaching psychopharmacology and improving clinical practice . J Clin Psychopharmacol. 2005;25:203-205. 2. Goldberg DA. Model curricula. The way we teach, the way we learn. Acad Psychiatry. 2001;25:98-101. 3. Glick ID, Janowsky DS, Zisook S, et al. How should we teach psychopharmacology to residents? Results of the initial experience with the ASCP model curriculum. Acad Psychiatry. 2001;25:90-97. 4. Glick ID, Zisook S. The challenges of teaching psychopharmacology in the new millennium: the role of curricula. Acad Psychiatry. 2005;29:134-140. 5. Glick ID, Janowsky DS, Salzman S, Shader RI. A proposal for a model psychopharmacology curriculum for psychiatric residents. Neuropsychopharmacology. 1993;8:1-5.