How to Succeed in Psychiatry

How to Succeed in Psychiatry

A Guide to Training and Practice

EDITED BY

ANDREA FIORILLO MD PhD

Professor of PsychiatryUniversity of Naples SUN, Italy

IRIS TATJANA CALLIESS MD PhD

Department of Psychiatry, Social Psychiatry and PsychotherapyInstitute for Standardized and Applied Hospital ManagementHanover School of Medicine, Germany

HENNING SASS MD

Medical DirectorChairman of the Board, and Professor of PsychiatryHospital of the University of TechnologyRWTH Aachen, Germany

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Library of Congress Cataloging-in-Publication Data

How to succeed in psychiatry : a guide to training and practice / edited byAndrea Fiorillo, Iris Calliess, and Henning Sass.

p. ; cm.Based on: Professione psichiatra / a cura di Andrea Fiorillo, Mariano Bassi,

Alberto Siracusano. 1. ed. 2009.Includes bibliographical references and index.ISBN 978-1-119-99866-2 (cloth)I. Fiorillo, Andrea. II. Calliess, Iris Tatjana. III. Sass, Henning.

IV. Professione psichiatra.[DNLM: 1. Psychiatry. 2. Professional Practice. 3. Psychiatry–education.

4. Vocational Guidance. WM 21]616.89–dc23

2011043614

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print maynot be available in electronic books.

Typeset in 10/12.5pt Meridien by Laserwords Private Limited, Chennai, India.

First Impression 2012

Contents

List of contributors vii

Preface xi

1 Training in psychiatry today: European and US perspectives 1Martina Rojnic Kuzman, Kajsa B. Norstrom, Stephanie Colin, ClareOakley and Joseph Stoklosa

2 How to start a research career in psychiatry 18Domenico Giacco, Mario Luciano, Sameer Jauharand Andrea Fiorillo

3 Publications in psychiatry: how to do and what to do 36Amit Malik and Gregory Lydall

4 Training in psychotherapy: where are we now? 50Clare Oakley, Larissa Ryan and Molly McVoy

5 Training in community psychiatry 64Giuseppe Carra, Paola Sciarini, Fiona Nolan and Massimo Clerici

6 Why, what and how should early career psychiatrists learnabout phenomenological psychopathology? 82Umberto Volpe and Henning Sass

7 The psychiatrist in the digital era: new opportunities and newchallenges for early career psychiatrists 98Umberto Volpe, Michael Davis and Davor Mucic

8 Portrayals of mental illness in different cultures: influence ontraining 122Joshua Blum and Sameer Jauhar

9 Recruitment of medical students into psychiatry 136Adriana Mihai, Otilia Butiu and Julian Beezhold

10 Not quite there yet? The transition from psychiatric trainingto practice as a psychiatric specialist 147Florian Riese, Virginio Salvi, Paul J. O’Leary and Corrado De Rosa

v

vi Contents

11 When things go wrong: errors, negligence, misconduct,complaints and litigation 161Julian Beezhold, Stavroula Boukouvala, Nya Maughn and KateManley

12 New ways of working: innovative cross-sector care in acompetitive mental health environment 182Kai C. Treichel and Magdalena Peckskamp

13 Choosing a career in psychiatry and setting priorities 197Joshua Blum and Andrea Fiorillo

14 How to collaborate with other specialties 211Silvia Ferrari, Joshua Blum and Patrick Kelly

15 Where they need us. . . Opportunities for young psychiatriststo help in developing countries 236Felipe Picon

16 Professional responsibility in mental health: what earlycareer psychiatrists really need to know 246Alexander Nawka and Gregory Lydall

17 The role of ethics in psychiatric training and practice 259Cecile Hanon, Defne Eraslan, Dominique Mathis,Abigail L. Donovan and Marianne Kastrup

18 Coercive measures and involuntary hospital admissionsin psychiatry 273Valeria Del Vecchio, Andrea Fiorillo, Corrado De Rosaand Adriana Mihai

19 Mental health problems of early career psychiatrists:from diagnosis to treatment strategies 283Nikolina Jovanovic, Julian Beezhold, Adriana Mihai, OlivierAndlauer, Sarah Johnson and Marianne Kastrup

20 Leadership, management and administrative issuesfor early career psychiatrists 296Julian Beezhold, Kate Manley, Emma Brandon, Victor Buwaldaand Marianne Kastrup

21 Why should I pay for it? The importance of being membersof psychiatric associations 311Andrea Fiorillo, Iris Tatjana Calliess and Domenico Giacco

Index 325

List of contributors

Olivier AndlauerDepartment of Psychiatry,

University Hospital, Besancon,France

Julian BeezholdNorfolk and Waveney Mental

Health NHS Foundation Trust,United Kingdom, University ofEast Anglia, Norwich, UK

Joshua BlumDepartment of Psychiatry,

University of MassachusettsMedical School, Worcester,MA, USA

Stavroula BoukouvalaNorfolk and Waveney Mental

Health Care NHS FoundationTrust, Norwich, UK

Emma BrandonNorfolk and Waveney Mental

Health NHS Foundation Trust,Norwich, UK

Otilia ButiuPsychiatric Department,

University of Medicine andPharmacy Tg Mures, Romania

Victor BuwaldaAltrecht ggz, Utrecht/Den Dolder

and Department of Psychiatry,

Free University of Amsterdam,The Netherlands

Iris Tatjana CalliessDepartment of Psychiatry, Social

Psychiatry and Psychotherapy,Institute for Standardized andApplied Hospital Management,Hannover School of Medicine,Germany.

Giuseppe CarraDepartment of Mental Health

Sciences, University CollegeMedical School, London, UK;

Department of Neurosciences andBiomedical Technologies,University of Milano BicoccaMedical School, Monza, Italy

Massimo ClericiDepartment of Neurosciences and

Biomedical Technologies,University of Milano BicoccaMedical School, Monza, Italy

Stephanie ColinAP-HP, Hopital Avicenne, Service

de psychopathologie del’enfant, de l’adolescent,psychiatrie generale etaddictions, Bobigny, France

Michael DavisDepartment of Psychiatry and

Biobehavioral Sciences, Semel

vii

viii List of contributors

Institute, University ofCalifornia Los Angeles (UCLA),Los Angeles, CA, USA

Valeria Del VecchioDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Corrado De RosaDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Abigail L. DonovanHarvard University,

Massachusetts GeneralHospital, Boston, MA, USA

Defne EraslanDepartment of Psychiatry,

Faculty of Medicine, AcibademUniversity, Istanbul, Turkey

Silvia FerrariDepartment of Mental Health,

University of Modena andReggio Emilia, Policlinico diModena, Italy

Andrea FiorilloDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Domenico GiaccoDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Cecile HanonEPS Erasme, Antony, France

Sameer JauharSackler Institute of

Psychobiological Research,Institute of NeurologicalSciences, Southern GeneralHospital, Glasgow, UK

Sarah JohnsonDepartment of Psychiatry,

University of Louisville, KY,USA

Nikolina JovanovicDepartment of Psychiatry,

University Hospital Centre andZagreb School of Medicine,Croatia

Marianne KastrupCentre Transcultural Psychiatry,

Psychiatric CentreCopenhagen, Denmark

Patrick KellyDivision of Child and Adolescent

Psychiatry, Department ofPsychiatry and BehavioralSciences, The Johns HopkinsHospital, Baltimore, MD, USA

Mario LucianoDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Gregory LydallCastel Hospital, La Neuve Rue,

Guernsey; University CollegeLondon, London, UK

Amit MalikSouthern Health NHS

Foundation Trust, AerodromeHouse, Gosport, UK

List of contributors ix

Kate ManleyNorfolk and Waveney Mental

Health Care NHS Foundation

Trust, Norwich, UK

Dominique MathisInstitut Paul Sivadon, Hopital de

l’Elan Retrouve, Paris, France

Nya MaughnNorfolk and Waveney Mental

Health Care NHS Foundation

Trust, Hellesdon Hospital,

Norwich, UK

Molly McVoyUniversity Hospitals of

Cleveland/Case Western

Reserve, Cleveland, OH, USA

Adriana MihaiPsychiatric Department,

University of Medicine and

Pharmacy Tg Mures, Romania

Davor MucicPsychiatric Centre ‘‘Little Prince’’,

Copenhagen, Denmark

Alexander NawkaDepartment of Psychiatry, First

Faculty of Medicine, Charles

University, Prague, Czech

Republic

Fiona NolanCentre for Outcomes Research

and Effectiveness (CORE), Sub

Department of Clinical Health

Psychology, University College

London, London, UK

Kajsa B. NorstromPsychiatric Unit Angered, Capio

Lundby Hospital, Goteborg,Sweden

Clare OakleySt Andrew’s Academic Centre,

Institute of Psychiatry, King’sCollege London, London, UK

Paul J. O’LearyDepartment of Psychiatry, Emory

University, Atlanta, Georgia,USA

Magdalena PeckskampDepartment of Psychology,

University of Vienna, Austria

Felipe PiconDepartment of Psychiatry,

Federal University of RioGrande do Sul, Porto Alegre,RS, Brazil

Florian RiesePsychiatric University Hospital

Zurich, Switzerland

Martina Rojnic KuzmanDepartment of Psychiatry, Zagreb

University Hospital Centre andZagreb School of Medicine,Zagreb, Croatia

Larissa RyanWarneford Hospital, Oxford, UK

Virginio SalviMood and Anxiety Disorders

Unit, Department ofPsychiatry, University of Turin,Italy

x List of contributors

Henning SassDepartment of Psychiatry,

University of TechnologyRWTH, Aachen, Germany

Paola SciariniDepartment of Neurosciences and

Biomedical Technologies,University of Milano BicoccaMedical School, Monza, Italy;

Department of Health Sciences,Section of Medical Statisticsand Epidemiology, Universityof Pavia Medical School, Pavia,Italy

Joseph StoklosaHarvard Medical School, McLean

Hospital, Boston, MA, USA

Kai C. TreichelMedical Center Friedrichshain

Berlin, Germany

Umberto VolpeDepartment of Psychiatry,

University of Naples SUN,Naples, Italy

Preface

What does it take to become a psychiatrist today? What are the train-ing and educational needs for modern psychiatrists? What does it meanto be a psychiatrist today? What are the professional responsibilities ofpsychiatrists and of other mental health workers? And what will be theirperspectives in the future? These are only some of the questions we havetried to address in this book, promoted by the EPA Early Career Psychi-atrists Committee and the European Federation of Psychiatric Trainees,which includes 21 chapters by 50 authors from 16 different countries.

The book ‘‘How to succeed in psychiatry: a guide to training andpractice’’ is not a source of clinical information, but rather a survival guideto help young colleagues through the first years of practice. A ‘‘survival’’kit seems to be particularly needed by young psychiatrists in our days, whoare very different from colleagues starting their career only a few yearsago. The clinical choices of young psychiatrists today seem to be drivenpredominantly by the need to avoid professional errors rather than thewish to find the best and most effective therapeutic treatment. In clinicalpractice, young psychiatrists quite often adopt ‘‘defensive’’ medical stylesin order to avoid complaints and litigation with patients, family members,stakeholders and also with managers. More often than in the past, youngpsychiatrists report not being able to bear stressful working situationsand experiencing high levels of burn-out, with anxiety and depressivesymptoms. Belonging to scientific and professional associations is oneway to prevent these feelings and to improve young doctors’ skills. Otherways to overcome these possible difficulties are reported in this book;they include setting the correct priorities for one’s own life and career orchoosing the ‘‘right’’ career among the various possibilities (e.g. privatepractice, community or hospital settings, academic career).

The volume is organized as an ideal path from training to employment,presenting all the relevant difficulties of being a psychiatrist today, aswell as possible solutions, being represented. The book opens with anoverview of psychiatric training, describing the similarities and differencesamong various countries. Subsequent chapters address the opportunitiesfor research studies and for getting the results published. Chapters 4 and 5describe training in psychotherapy and in community psychiatry, both ofwhich are particularly relevant for young psychiatrists, as they representtwo of the most frequent possible working scenarios. In chapter 7the importance of telecommunication resources for the psychiatricprofession and the risks associated with the use of new technologiesare described. Chapter 8 addresses cultural factors that can influence

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xii Preface

psychiatric training. Chapter 9 deals with the problem of the shortage ofpsychiatrists, focusing on the transition from medical school to trainingin psychiatry.

Next, the book guides the reader through the transition phase into ajob, discussing job opportunities in both the public and private sectorsand suggesting how to choose the best career. Chapter 12 deals withjob opportunities in the private sector; this is an ever-expanding sectorand often represents one of the first employment opportunities afterspecialization. In chapter 19 the topics of mental health, work stress andburnout, to which mental health professionals seem to be particularlyvulnerable, are addressed. Authors report data from the literature showingan increased risk of stress in younger colleagues and provide, at the sametime, practical advice that we should all learn to follow.

The following section of the book reviews important general and legalconsiderations, such as ethics, professionalism, leadership and manage-ment, and how to liaise with other specialties. Professional responsibilityin medicine today is a ‘‘hot’’ issue, and the emphasis given to this topicreflects the sensitivity of young psychiatrists to these issues. What theauthors of this volume have not lost is the ethics of medical work.Chapter 17 is a useful discussion of the most significant ethical anddeontological aspects of medicine in general, not only of psychiatry. Inchapter 18 practical suggestions regarding compulsory hospital treatmentsand the use of coercive measures are offered. Again, this is a hotly-debatedissue in clinical psychiatry, for which early career psychiatrists do not seemto have all the necessary information, being too often overlooked in thecurricula of psychiatrists. The book closes with an account of the role ofpsychiatric associations and continuing professional development.

Although this book is aimed mainly at recently qualified psychiatristsor those looking to qualify soon, we believe it will be useful for allpsychiatrists, including more experienced colleagues: while reading thebook, they will go back in time to when they were young psychiatristsand re-experience the curious and exploratory approach to life, whichis – in our opinion – the true essence of being a psychiatrist today. Wehope that young psychiatrists worldwide will succeed in their aims andcareers, but will never lose this attitude of ‘‘curious determination’’ thatbrought them to choose psychiatry.

We are grateful to a number of people. It is almost impossible to nameall of them. Basically, we want to thank here our contributors, whohave provided excellent chapters and who have enthusiastically joinedthis initiative; the leadership of the European Psychiatric Association,which has supported us throughout the preparation of the book;Professors Bhugra and Sartorius, for their valuable advice in selectingchapters and authors; Joan Marsh and her team at Wiley-Blackwell. Weare greatly indebted and grateful to all of them.

Andrea Fiorillo, Iris Tatjana Calliess, Henning Sass

CHAPTER 1

Training in psychiatry today:European and US perspectivesMartina Rojnic Kuzman,1 Kajsa B. Norstrom,2 Stephanie Colin,3

Clare Oakley4 and Joseph Stoklosa5

1Department of Psychiatry, Zagreb University Hospital Centre and Zagreb School ofMedicine, Zagreb, Croatia2Psychiatric Unit Angered, Capio Lundby Hospital, Goteborg, Sweden3AP-HP, Hopital Avicenne, Service de psychopathologie de l’enfant, de l’adolescent,psychiatrie generale et addictions, Bobigny, France4St Andrew’s Academic Centre, Institute of Psychiatry, King’s College London, UK5Harvard Medical School, McLean Hospital, Boston, MA, USA

Introduction

The last few decades have brought rapid social changes, which havegreatly influenced health, communication, ethics, politics and economics.Psychiatry, as a significant component of the health-care system, hasalso been affected by these changes. Nowadays, trainees and early careerpsychiatrists worldwide are facing several challenges, quite different fromthose faced previously. Young psychiatrists acquire the competenciesrequisite of a mental health professional through medical schools andpostgraduate residency trainings, and this formative stage is crucial forthe development of competent mental health professionals.

Psychiatric training in Europe

In Europe, training programmes in psychiatry are developed and subse-quently implemented by educational policy-makers, at national levels ineach European country. Accreditation policy as well as quality assurancemechanisms also fall within the remit of authorities at national levels. Theneed for harmonized postgraduate training in psychiatry has developed

How to Succeed in Psychiatry: A Guide to Training and Practice, First Edition.Edited by Andrea Fiorillo, Iris Tatjana Calliess and Henning Sass.© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.

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2 Chapter 1

in parallel with the development of the European Union. Today, theSection and Board of Psychiatry of the Union Europeenne des MedecinsSpecialistes (UEMS) play an active part in shaping the future of Euro-pean psychiatrists. UEMS was established in 1958 as a response to thesigning of the Treaty of Rome in 1957, where harmonization and mutualrecognition of diplomas was foreseen.1 In 1990, the Section of Psychiatrywas formed to deal primarily with general issues related to psychiatricpractice and quality assurance of psychiatric care. In 1992 the Board ofPsychiatry was formed, focusing on training issues. In 1993 the Treatyof Maastricht was signed on an EU level, which opened up the internalmarket and free movement of goods, persons, services and capital. Today,27 European countries benefit from this Treaty, and in the last decadethis has been reflected in an increasing migration of psychiatric traineesand psychiatrists across Europe.

Due to the observed huge variations in training standards, training pro-grammes and training facilities in European countries, in 1993 the UEMSpublished the Charter of specialist training.2 The Section and Board ofPsychiatry have drafted and approved numerous reports and guidelinesto enhance the speed and recognition of the harmonization process inpsychiatric training. These documents concern several areas, such as train-ing in psychotherapy, supervision, quality assurance and accreditation oftraining schemes in psychiatry, and in 2009 a European framework forcompetencies in psychiatry was published.3 These documents are consid-ered as guidelines and it is intended that the member countries use themin order to reform their national training programmes. UEMS has no legalauthority to enforce changes in any particular country; therefore, it isimportant to have a continuous process of discussion and to promote asupportive attitude in order to make progress with the harmonization ofpsychiatric training.

Trainees’ perspectives in Europe are represented by the European Fed-eration of Psychiatric Trainees (EFPT), the first and only internationalorganization of national psychiatric trainees’ associations. EFPT has fullvoting rights at the European Board of Psychiatry of the UEMS, contribut-ing significantly to the cooperation between the two organizations. TheFederation has grown rapidly over the years and currently encompassesmore 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 smalladults’. Nevertheless, the core identity of child and adolescent psychiatryhas been at stake for the last few decades. Whereas in most Europeancountries CAP has slowly grown to become an independent specialty,separated from adult psychiatry, in others it is still a subspecialty or isstill strongly linked with paediatrics. Hence, there are huge discrepancies

Training in psychiatry today: European and US perspectives 3

in the training programmes in CAP in Europe. Within the UEMS, CAPpsychiatrists used to be represented in the Section and Board of Psychiatry,until the establishment of a separate Section and Board in 1992. The ideasbehind this initiative to split within the UEMS were to promote highstandards of mental health care for children across Europe, both directlyand indirectly, by establishing standards and improving the quality ofpostgraduate CAP training, with a particularly strong emphasis on trainingin psychotherapy.5

Again, the perspective of European CAP trainees is represented by theEFPT, which now provides a valuable framework for European child andadolescent psychiatry trainees to discuss and exchange ideas. Its innerstructure has recently been modified in response to the growing identityclaims of CAP trainees, as a new board position for a ‘CAP secretary’was created, allowing specific representation of CAP trainees in EuropeanCAP meetings, and enhanced links with international organizations,such as UEMS-CAP and the European Society for Child and AdolescentPsychiatrists (ESCAP).

Psychiatric training in the USA

The young psychiatrist training and practising in the USA today facesa different set of challenges than the psychiatrist training just a fewdecades ago. The structure of psychiatric training itself has shifted from aparticipation-based into a competency-based model, in response to pres-sures from government, practitioners and patients to make physiciansmore accountable to the public. Psychiatric training is regulated by asingle governing body for all US residencies, which is a private, non-profitcouncil called the Accreditation Council for Graduate Medical Education(ACGME). The ACGME was established in 1981 from demands in the aca-demic medical community for an independent crediting association withthe mission to ‘improve health care by assessing and advancing the qual-ity 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 theAmerican Medical Association (AMA) and individual specialty boards. Itis these RRCs that then determine the specific programme requirementsfor each specialty training programme, including psychiatry. RRCs alsohave direct oversight on each specific training programme institution toensure sufficient support within each programme. Each residency trainingprogramme submits to a review by its RRC at least every 5 years. Duringreview, each programme provides extensive information on all aspects oftraining, which is then verified by the site visit to solicit trainee and facultyfeedback, and make direct observations on patient care, staff and facilities.7

4 Chapter 1

In 1959, child and adolescent psychiatry was established as anofficial subspecialty of general psychiatry. Residents wishing to pursuethis subspecialty can enter the two-year fellowship after either their thirdor fourth year of general psychiatry training. The core requirements ofchild and adolescent specialty training also fall under the purview of thepsychiatry RRC.

Around this system of regulation, several unique situations in USculture have evolved that sculpt the modern psychiatry resident’s expe-riences, including the rise of core competency-driven education, theadvent of national duty hours regulations, and the US health-care systemof managed care.

State of the art of psychiatric training in Europe

For the majority of European countries, curricula for psychiatric trainingacross Europe are set by national authorities. In a significant proportionof European countries, the curricula are developed in accordance withthe UEMS requirements for the specialty of psychiatry and standards,as defined in the document called the ‘Charter on training of medicalspecialists in the EU: requirements for the specialty of psychiatry’.2 Aselection of the UEMS recommendations is given in Table 1.1.

While in most European countries the structures of training pro-grammes are reasonably compatible with standards set by the UEMS, theduration of different placements, as well as the duration of training asa whole, varies across Europe. This is more pronounced in some partsof Europe – the shorter duration of training is seen in some parts ofEastern and southeastern European countries, but not in all countries.There are great differences in the psychiatric trainees’ assessment beforethey become specialists: some countries have neither examinations norother methods of assessment, while other countries employ a range ofassessment methods, including different types of examination, workplace-based assessments, portfolios and supervisor’s reports.8 An overview ofthe structure of training programmes in Europe is given in Table 1.2.

Recently, a UEMS survey aiming to find out whether the UEMSdirectives had an impact on the conditions of psychiatry training acrossEurope was conducted.9 The authors concluded that while there weregreat differences between the training centres in different countries,progress towards developing high standards had been made. The partsof the training programmes that display major variations and thatshow little coherence even within a country seem to be supervision(especially educational supervision) and psychotherapy training.9 Thesefindings are compatible with recent EFPT data, where the most impor-tant problems faced by postgraduate psychiatric trainees across countries

Training in psychiatry today: European and US perspectives 5

Table 1.1 A selection of requirements for the specialty of psychiatryaccording to charter on training of medical specialists in the EU releasedby the Union Europeenne des Medecins Specialistes (UEMS).2

Article Content

CENTRAL MONITORING AUTHORITY FOR PSYCHIATRY (defines the requirements forthe monitoring Authority, the recognition of teachers and training Institutions, qualityassurance mechanisms and recognition of quality)

GENERAL ASPECTS OFTRAINING IN PSYCHIATRY(in addition, it defines theselection and access to thetraining, the circumstances ofthe interruption of training,training abroad and funding)

Training duration

The minimum duration of training will be 5 years inpsychiatry; can take place in different institutionsif they are recognized nationally as traininginstitutions; part-time training should be possiblein every EU member state

Definition of common trunk

Within the national training programme inpsychiatry there is a common trunk offundamental knowledge and skills that isrequired of all candidates. The common trunk iscompulsory. This common trunk includes trainingin inpatient psychiatry (short, medium and longstay), outpatient psychiatry (communitypsychiatry, day-hospital), liaison and consultationpsychiatry, and emergency psychiatry.Psychotherapy training is also part of thecommon trunk. Training should cover generaladult psychiatry, old age psychiatry, psychiatricaspects of substance misuse, developmentalpsychiatry (child and adolescent psychiatry,learning difficulties and mental handicap) andforensic psychiatry. The training programme caninclude not more than one year of flexibletraining (e.g. research or other related subjectsto be approved by the head of training)

Practical training

Practical training should evolve around routineclinical work under supervision. As trainingprogresses there should be an increasing level ofresponsibility. During the period of trainingrotation within different sections of aninstitution should be compulsory. Rotation todifferent institutions should be facilitated

(continued overleaf )

6 Chapter 1

Table 1.1 (Continued)

Article Content

Supervision

Clinical supervision should be available on a dailybasis. In addition to clinical supervision andpsychotherapy supervision, individualeducational supervision (dealing with suchsubjects as attitude, growth in the profession,etc.) is compulsory for a minimum of 1 hour perweek, at least 40 weeks per year

Implementation of training programme/traininglogbook

The theoretical and practical training will follow anestablished programme approved by the nationalauthorities in accordance with national rules andEU legislation as well as with the requirementsand recommendations of the European Board ofPsychiatry. The different stages and the activitiesof training and the activities of trainees shouldbe recorded in a training logbook

APPENDIX 1: Theoretical training

Training should include a structured training(lectures, seminars, etc.) over 4 years, on averagefor 4 hours per week. The subjects to be coveredare the scientific basis of psychiatry,psychopathology, examination of a psychiatricpatient, diagnosis and classification,psychological tests and laboratory investigations,specific disorders and syndromes, child andadolescent psychiatry, mental handicap,psychiatric aspects of substance misuse, old agepsychiatry, diversity in psychiatry, legal, ethicaland human rights issues in psychiatry,psychotherapies, psychopharmacology and otherbiological treatments, multidimensional clinicalmanagement, community psychiatry, socialpsychiatric interventions, research methodology,epidemiology of mental disorders, psychiatricaspects of public health and prevention, medicalinformatics and telemedicine, leadership,administration, management, economics

(continued overleaf )

Training in psychiatry today: European and US perspectives 7

Table 1.1 (Continued)

Article Content

APPENDIX 2: Training in psychotherapy

Psychotherapy is an integral part of training inpsychiatry. The content that is consideredessential for training in psychotherapy include amandatory part of the training curriculum thattakes place within working hours, practicalapplication of psychotherapy in a definednumber of cases, theory of psychotherapy over atleast 120 hours, supervision provided on aregular basis for at least 100 hours, individual (atleast 50 hours) but preferably also groupsupervision. Experience should be gained with abroad range of diagnostic categories, includingassessment and evaluation of outcome.Experience in psychotherapy should be gainedwith individuals as well as families and groups.As a minimum, psychodynamic, cognitivebehavioural therapy (CBT), and systemic theoryand methods should be applied, but integrativepsychotherapies are highly recommended.Personal therapeutic experience/feedback onpersonal style is highly recommended. Researchmethodology should be included

Training should if possible take place withindifferent parts of mental health services.Supervisors should be qualified. Training shouldbe publicly funded

REQUIREMENTS FOR TRAINING INSTITUTIONS (defines the criteria for the recognitionof training institutions, their size and the quality assurance of training institutions)

REQUIREMENTS FOR TEACHERS (defines the qualification of the chief of training andthe training programme)

REQUIREMENTS FOR TRAINEES (defines the required experience, language skills andspecialization for trainees)

8 Chapter 1

Table 1.2 Training programmes for adult psychiatry across Europe.

Country Duration Structure of Assessments Separate Meetingof training and CAP UEMStraining programme examinations training recommen-(years) dations

Austria 5 NA Examinations

Portfolio

Yes Yes, in part

Belarus 1 Only covered acutepsychiatric care,outpatients, substanceabuse, dailyprogrammes, CAP,rehabilitation

Examinations

Portfolio

No No

Belgium 5 Basic schema∗ Examinations

Portfolio

No Yes,significantly

Bosnia 4 Three programmes, butin one followed thebasic schema∗, but noold age, liaison

Examinations

Portfolio

No Yes, in part

CzechRepublic

5.5 Basic schema∗, butfulfilled therequirements forpsychotherapy, noliaison and forensics

Examinations

Portfolio

No Yes,significantly

Croatia 4 Basic schema∗, no oldage, liaison

Examinations

Portfolio

No Yes, in part

Denmark 5 Basic schema∗, no liaison Yes Yes,significantly

Estonia 4 Basic schema∗, no old agepsychiatry, no liaisonand forensics

Examinations

WPBA

Portfolio

No Yes,significantly

Finland 6 Basic schema∗ Examinations

Portfolio

Yes Yes,significantly

France 4 Basic schema∗, nopsychotherapy

None No Yes,significantly

Germany 5 Basic schema∗, noforensics, no liaisonplus neurosurgery/neuropathology

Examinations

Portfolio

Yes Yes, in part

Greece 5 Basic schema∗, nopsychotherapy, noliaison

Examinations Yes Yes, in part

Ireland 6 Basic schema∗ Examinations

WPBA

Portfolio

Yes Yes,significantly

Italy 5 Basic schema∗, nopsychotherapy, no oldage

Examinations Yes Yes,significantly

(continued overleaf )

Training in psychiatry today: European and US perspectives 9

Table 1.2 (Continued)

Country Duration Structure of Assessments Separate Meetingof training and CAP UEMStraining programme examinations training recommen-(years) dations

Latvia 4 Basic schema∗plusrehabilitation

Examinations

Portfolio

No Yes, in part

Lithuania 4 Basic schema∗ Examinations

Portfolio

NA Yes, in part

Malta 5 Basic schema∗ Examinations

Portfolio

NA Yes,significantly

Netherlands 4,5 Basic schema∗ Examinations

WPBA

Portfolio

Yes Yes,significantly

Norway 5 Basic schema∗ Portfolio Yes Yes, in partPoland 5 Basic schema∗, no old age Examinations

Portfolio

Yes Yes,significantly

Portugal 5 Basic schema∗, no oldage, no psychotherapy

Examinations Yes Yes,significantly

Romania 5 Basic schema∗ Examinations

Portfolio

Yes Yes,significantly

Russia 2 NA NA No NoSerbia 4 Basic schema∗, no old age

and psychotherapy,liaison

Examinations

Portfolio

Yes Yes, in part

Slovakia 5 Basic schema∗, no liaison Examinations

Portfolio

Yes Yes, in part

Slovenia 5 Basic schema∗, no liaison Examinations

Portfolio

Yes Yes,significantly

Sweden 5 Basic schema∗, no liaison Portfolio Yes Yes,significantly

Switzerland 6 Basic schema∗ Examinations

WPBA

Portfolio

Yes Yes,significantly

Turkey 5 Basic schema∗, no oldage, liaison, nopsychotherapy

Examinations

Portfolio

Yes Yes,significantly

UK 6 Basic schema∗ Examinations

WPBA

Portfolio

Yes Yes,significantly

Ukraine 1.5 Inpatient psychiatry,outpatient psychiatry,drug abuse

Examinations No No

∗Basic schema = training in in-patient psychiatry (short, medium and long stay), outpatientpsychiatry (community psychiatry, day-hospital), liaison and consultation psychiatry, andemergency psychiatry in general adult psychiatry, old age psychiatry, psychiatric aspects ofsubstance misuse, developmental psychiatry, and forensic psychiatry.∗CAP, child and adolescent psychiatry; UEMS, Union Europeenne des Medecins Specialistes;WPBA, workplace-based assessments.

10 Chapter 1

were implementation of postgraduate curricula, psychotherapy trainingand lack of supervision.10 Problems with the implementation of train-ing programmes are related to the implementation of newly developedprogrammes in some countries, while in others there is a significant gapbetween the conception of the training systems that are prescribed bythe national educational bodies and their delivery at a local level. Thisissue might be related to the overall shortage of psychiatrists,11 leavingthe trainees without proper educational and clinical supervision, but alsoleaving the trainees to engage in the tasks of fully trained specialists,which they are not yet competent to do. It may also be due to the lack ofaccredited or high quality facilities in many parts of Europe (especially ineastern and southern countries) and to the heterogeneity of standards oftraining in different centres, even within the same country, with a con-sequent relative overload of trainees in some placements and thus longwaiting lists for some rotations. Another reason for explaining implemen-tation problems of training programmes might be the lack of adherenceto the recommended quality assurance mechanisms at the national andinternational levels.

In recent years, a significant shift in the philosophy of training hasoccurred. As the result of the work of the UEMS and of nationalauthorities in several European countries, a competency-based frameworkfor training, including a competency-based curriculum and assessmentprogrammes ranging from workplace-based assessments to exit examina-tions, was designed and it is now being implemented in several Europeancountries.12 Whilst this introduction of competency-based training repre-sents a major shift in medical education, new challenges arise with thistransition, due to the high demands on trainers to deliver this relativelyintensive method of providing postgraduate training and to the new reg-ulations for residents. Nevertheless, the benefits of the new programmeare clear and, thus, it is firmly supported by both the UEMS and the EFPT.

Although European child and adolescent psychiatry has undergoneimpressive development over the past 50 years, there is still a hugevariability in the structure of CAP training across Europe, and a longway to go for full harmonization in the programs. CAP is now anindependent specialty in more then 20 countries and a subspecialty inthe rest of them, but some countries still do not have any structuredCAP training curriculum (Table 1.2).13 One of the main achievementsof the UEMS CAP Board was to publish a training logbook, which hasbeen implemented at least partially in two-thirds of the countries.14 Itspecifically states that the minimum duration of postgraduate trainingshould be 5 years, of which 4 years should be pure CAP. Trainingdifferences are marked even within the EU member countries, and notonly in terms of content of training programmes, but also of duration,

Training in psychiatry today: European and US perspectives 11

trainee selection and graduation procedures. Moreover, a lack of detailedinformation regarding training curricula in several countries has also tobe acknowledged. While the UEMS-CAP logbook emphasizes trainingin psychotherapy as being mandatory, only half of the countries haveintegrated structured psychotherapy training as a full component of CAPtraining. Interestingly, trainees in almost all countries have to pay withtheir personal funds for their psychotherapeutic education within CAPtraining. In virtually all European countries, experience in psychiatrywith adults of working age is a necessary component of training in CAP.Similarly, experience in paediatrics is welcome, or required, in manycountries. Training in research, however, is integrated as a structured partof the training only in one-third of the countries.

Leaving the tradition of any particular country aside, and devisingan adequate yet realistic training schedule that would incorporate suchexperiences, the UEMS CAP Board recommended a 12-month minimumtime for training in adult psychiatry. Similar rotations in paediatrics orneurology are recommended, but they are optional. The logbook hasalready proven to be important in helping new EU member countriesto develop their own training programme in CAP.15 However, standardsset in the logbook are high and may well exceed those set by relevantauthorities in each country: they should therefore be inspirational.

State of the art of psychiatric training in the USA

The Accreditation Council for Graduate Medical Education policy definesa set of specific requirements for psychiatric training programmes thatare seeking accreditation. Currently, residency education in psychiatryrequires 4 years of training.16 Thus, the newly graduated doctor, havingjust completed medical school, must undertake an additional 4 years oftraining prior to practising as an independent physician. The first year oftraining includes 4 months in a primary care setting (internal medicine,family medicine and/or paediatrics), and 2 months in neurology. The sec-ond 6 months can comprise additional medical training or introductorypsychiatry training. The second year of residency marks the true begin-ning of psychiatry training; this includes at least 9 months of inpatientpsychiatry and 12 months of continuous outpatient psychiatry that usesboth psychotherapy and biological therapies. Additional requirementsexist to ensure diversity of experience within the inpatient and outpatienttraining, including at least 2 months of child and adolescent psychia-try, 1 month of geriatric psychiatry, 1 month of addiction psychiatry,and 2 months of consultation/liaison psychiatry. Residents must alsohave clinical experience in the following areas: forensic psychiatry, emer-gency psychiatry, community/public sector psychiatry, group, couples

12 Chapter 1

and family therapy, and psychological testing. Residents must participatein a didactic curriculum that includes neurobiology, psychopharmacol-ogy, major theories of psychotherapy, child development and culturalissues in psychiatry. Training must encompass a wide variety of clinicalexperiences with different patient populations. The ACGME is committedto achieving a balance between psychodynamic and biological psychiatry,in both education and clinical care.

Beyond the specific educational components, the ACGME also sets rec-ommendations on the hierarchical structure of programmes and specificmonitoring parameters. These various requirements include regulationsfor necessary programme personnel, faculty qualifications, educationalresources, specific competencies, scholarly activities’ participation, resi-dent and faculty evaluations, and duty hours. In order to meet ACGMEcertification, these requirements must all be met during RRC review.

The ACGME previously guided psychiatric training by a set of‘minimum standards’ that needed to be met by each trainee in order tocomplete training. These ‘minimum standards’ were met through com-pletion of the required rotations and clinical experiences; thus, the modelwas largely participation-based.17 Each training programme was respon-sible for defining and implementing its own system to assess satisfactoryperformance on these required rotations. However, in 2000 the ACGMEdramatically changed the requirements for education assessment frommerely participation-based to competency-based. The idea of measuringcompetence grew out of a culture in the USA that prized directlymeasurable outcomes. This ‘outcomes movement’ began in the 1980sin a variety of non-medical industries, such as aviation and business,with great success.17 In medicine, this movement followed society’s shifttoward research and evidence-based outcomes and away from traditionalphysician judgment and intuition. This was soon embodied nationallywith the establishment in 1989 of the Agency for Health Care Policy andResearch. The outcomes movement reached educational programmeswhen the Department of Education mandated that graduate educationalinstitutions shift to an outcomes model. In the 1990s, this model reachedresidency training when the ACGME endorsed its own definition ofoutcomes-based competence by defining a set of basic skills necessary forresidents to practise medicine. In 2000, the ACGME formalized its recom-mendations as the ‘six core competencies’, which now define the specificabilities and skills that comprise residency training and drive the focus forresident education. Residents must now demonstrate competency in thefollowing six areas: patient care (including clinical reasoning), medicalknowledge, practice-based learning and improvement, interpersonal andcommunication skills, professionalism and system-based practice.6 Whileeach programme may use individual models of assessment for each

Training in psychiatry today: European and US perspectives 13

competency, these universal core competencies have changed the focusand face of psychiatric training on a national level.

A second major shift in US residency training is the advent of strictduty hours limitations. The days of residents working 36-hour shifts, andup to 120 hours per week, are no more. In 2003 the ACGME passedits own work hours regulations for residents, which include: (i) weeklyduty hours must be no more than 80 hours per week; (ii) no shiftlonger than 24 hours, with an additional 6 hours for transfer of care;(iii) at least 10 hours off between shifts; (iv) call every third night or lessfrequently; and (v) one day off in seven.18 There is a debate regardingthe merits of duty hour regulations. Supporting duty hours regulation,studies show that residents make more serious medical errors, medicationerrors and diagnostic errors after long shifts in the intensive care unit.19

Given that psychiatric evaluation requires a high level of attentivenessto the patient and empathic responsiveness, it is felt by supporters thatthese regulations protect residents and patients alike from poor qualitytherapy, consultations or evaluations.20 Furthermore, for the increasingnumbers of physicians choosing specialties based on lifestyle, shorterwork hours allow for a new kind of professionalism and life balanceto emerge.

However, duty hour regulations also have a number of drawbacks.More frequent pass offs (handovers or transfer of care) may also leadto a decrease in alliance and connection with patients, which are centralto effective psychiatric care. There are worries that limited duty hoursare leading to less overall training per resident, less exposure to patientdiversity, and less direct patient contact.21 Given that early estimatesshowed 86% of all psychiatry residencies had some duty hour violations,more work must be done to understand better the harms and benefits ofthis new system.22

Another major shift in training followed the dramatic changes of thehealth-care system in the USA over the last several decades. In the 1990s,costs for medical care rose dramatically.23 The government and insurancecompanies supported ‘managed care’ as a way to decrease these costs.‘Managed care’ requires that medical services be approved by a patient’sprimary care physician or an insurance reviewer. It exists in severaldifferent forms, including health maintenance organizations, point ofservice, or preferred provider organizations, differing in fee structure and‘in network’ versus ‘out of network’ coverage. The goal of this systemwas to reduce unnecessary medical costs in order to preserve basic carefor the largest number of people. This theoretical construct has merit;however, managed care in the USA has led to challenges in providingappropriate services to psychiatric patients. Practically speaking, managedcare has created challenges in both the practice of psychiatry and patients’

14 Chapter 1

access to care, leaving only the most ill patients admitted to hospitals andshortening the length of hospitalizations. That in turn, besides leadingto reduced cost, may also represent cost shifting of those with severemental illness to the criminal justice system.23 The criminal justice systembecomes involved because many patients who do not qualify for aninpatient level of care, or who are discharged too quickly, may end upcommitting crimes as a result of their largely untreated mental illness,resulting in their imprisonment. Furthermore, many medications andmost long-term therapies also require prior authorization. Outpatient carehas now shifted to a focus on psychopharmacology and brief therapy,as managed care considers these more cost-effective treatments andwill approve payment for them more readily. Thus, briefer ‘15-minute’medication visits are becoming more prevalent in standard outpatientpractice, with an increase in prescribing psychotropic medication anddecrease in psychiatrists providing psychotherapy themselves. Becauseof this change, early career psychiatrists in the USA must now becomeskilful at short-term therapy and psychopharmacological managementunder strict time constraints, become familiar with which types of servicesare authorized by which insurers, and learn how to advocate effectivelyfor their patients’ needs with an insurance reviewer. Lastly, they mustknow how to accurately and effectively fill out insurance paperwork thatsometimes requires hours of extra work.

In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA)was approved by the US government. This act, which went into effect inlate 2009 and 2010, requires that insurance-based financial requirements(such as co-pays and deductibles) and treatment limitations (such as visitlimits) applicable to mental health and substance use disorders can beno more restrictive than the predominant requirements or limitations formedical and surgical illnesses. The effects of this act on care for patientswith psychiatric illness in the USA remain to be seen.

Conclusions and future perspectives

The last few decades have brought rapid and important social changes,greatly influencing health, communication, ethics, politics, economicsand, consequently, psychiatry. These global changes were also reflectedby the shift in requirements that trainees and early career psychiatristsworldwide must fulfil, which are very different from those required only afew decades ago. These social changes also influenced the development ofeducational programmes worldwide. Although there are globally sharedproblems for trainees and early career psychiatrists, there are still signifi-cant differences between the European and US educational systems, andthus psychiatry training programmes.

Training in psychiatry today: European and US perspectives 15

In Europe, one of the most challenging tasks for Europeanauthorities that develop and implement training programmes is still theharmonization of training programmes. This is one of the majorstrategies for improving scientific, working and educational activities inall European regions. This task is becoming more and more importantnow that the expansion of the EU has brought more countries withdifferent historical and socio-cultural backgrounds into the Union. Whileefforts towards the harmonization of psychiatric training in Europestarted a few decades ago, progress in this challenging task is slow,especially for the observed discrepancy between what is happening inrespect of training and what occurs in actual practice. The UEMS andthe EFPT, as the major players in psychiatric educational policies at thepan-European level, are working together to develop effective strategiesthat can enhance the full implementation of the harmonization process.The UEMS strategy and aims for the next decade include harmonizationof postgraduate medical training to the highest standards, includingevaluating performance and proposing changes. This will be achievedby advocating the harmonization of training based upon the publisheddocument ‘European framework for competencies in psychiatry’,12

which outlines the competencies and assessments required for psychiatrictrainees, and by the development of high-quality assurance mechanisms.In this perspective, developing stronger links with responsible nationaltraining authorities and bodies, and providing advice and feedback aboutthe development of high-quality psychiatric training programmes thatare nationally driven, are crucial. Moreover, proper executive powershould be allocated to the national bodies that are responsible for qualitycontrol, while international bodies, such as UEMS, should provide anadditional external quality control source by enhancing national clinicalvisits throughout Europe.

Psychiatric training in the USA needs to embody the ACGME corecompetencies as caring, informed, up-to-date, professional communica-tors able to function within the US health-care system. In the USA thereare strict limits on duty hours, requiring a mastery of more frequenttransfers of care. It is also essential to learn to function within a regulatedsystem of managed care via briefer outpatient visits and shorter inpa-tient stays; the effect of the Mental Health Parity and Addiction EquityAct remains to be seen. For psychiatrists entering the field today, thesenew challenges come at a time when psychiatry is rapidly expandingits knowledge base of diagnosis and treatment. European trainees havefaced similar challenges with a recent reduction in working hours to 48hours per week as a result of the European working time directive. Ashift to competency-based training is also beginning in many countries,as opposed to the participation-based model.

16 Chapter 1

Despite the still significant differences between the European and USeducational and health-care systems, and societal differences, globaliza-tion has contributed to the increase in global sharing of challenges amongthe communities of trainees and early career psychiatrists and to theformation of a ‘global community of young psychiatrists’. This fact is alsoevident by the formation of international networks of trainees and youngpsychiatrists aiming to serve as a platform allowing colleagues to shareand learn from each others’ experiences. In light of the growth of glob-ally shared challenges in psychiatric training, learning from internationalexperiences is crucial to develop more effective training systems. Ulti-mately, to succeed as psychiatrists, trainees worldwide must rememberthat their responsibility to their patients is paramount, and they mustlearn to effectively balance the demands of the health-care industry,training bodies and society.

References

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2. UEMS Section for Psychiatry. Charter on training of medical specialists inthe EU: requirements for the specialty of psychiatry. Eur Arch Psychiatry ClinNeurosci 1997; 247(Suppl.): S45–47.

3. UEMS Section and Board of Psychiatry (http://www.uemspsychiatry.org).4. European Federation of Psychiatric Trainees (http://www.efpt.eu).5. Hill P, Rothenberger A. Can we – and should we – have a neuropsychiatry

for children and adolescents? The work of the UEMS Section and Board forChild and Adolescent Psychiatry/Psychotherapy. Eur Child Adolesc Psychiatry2005; 14; 466–470.

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7. Bhatia SK, Bhatia SC. Preparing for a successful residency review commit-tee site visit: A guide for new training directors. Acad Psychiatry 2005; 29:249–255.

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9. Lotz-Rambaldi W, Schafer I, ten Doesschate R, Hohagen F. Specialist trainingin psychiatry in Europe – results of the UEMS-survey. Eur Psychiatry 2008;23: 157–168.

10. Nawka A, Rojnic Kuzman M, Giacco D, Malik A. Challenges of the postgrad-uate psychiatric training in Europe: a trainee perspective. Psychiatr Serv 2010;61: 862–864.

11. World Health Organization. MhGAP: Mental Health Gap Action Programme:scaling up care for mental, neurological and substance use disorders. 2008;available at: www.who.int/mental_health/mhgap_final_english.pdf.