Training GPs and others

in mental health skills

Course for Young PsychiatristsAddis Ababa, 27th April 2006

David GoldbergInstitute of Psychiatry

A WPA Training Package

Goldberg, Gask & Sartorius ; 2002

• A paper: “Training Physicians in Mental Health Skills”

• Five videotapes: on 3 CD-ROMs; containing five teaching sessions

• And files teaching notes for trainers, additional scales, and role- plays

A small box containing:-

The PaperGoldberg, Gask & Sartorius ; 2002

• Why is a course necessary?

• Methods of teaching

• Planning your own course

Headings:

Knowledge deficits; unhelpful attitudes; skill lack

Modelling; role play; using videos; micro-skills

Managerial; course content; training teachers

The VideotapesGoldberg, Gask & Sartorius ; 2002

• Depression• Unexplained somatic symptoms• Chronic fatigue• Psychosis• Dementia

Five programmes:

The Extra FilesGoldberg, Gask & Sartorius ; 2002

• The paper • Power point slides for a lecture on

skills• Notes for teachers on each video• Role plays suitable for each video

Four files:

Training in the United KingdomTraining in the United Kingdom

Training in the United Kingdom

We use the packs to train “GP tutors”, whose task it is to train future GPs.

Linda Gask uses the packs over a 12 week course, and has shown this is highly effective

But in London we are lucky to get the GPs for a single afternoon – so we have measured what can be achieved with this

Walters et al: training in a single afternoon

22 GP registrars in training; “Medically unexplained somatic symptoms” demonstrated, followed by role-plays

We measured their interviewing skills before the course, and 3 weeks afterwards

Walters et al., results:

doctors used a more “negotiating style”, and were rated as more empathic

they were better at “changing the agenda” they were better at “making links” between

distress and somatic symptoms they improved at telling patients why they

thought they were depressed and better at checking the patient’s

understanding of what had been learned

As a result of training,

HONG KONG

Training objectives in Hong Kong:

to train a GP tutor to take over the training after my visits stopped

To assist GP’s to diagnose depression To correct some of their

misunderstandings about drug treatments

To assist them dealing with unexplained somatic symptoms

To teach them “problem solving”

Teaching problem solving:

1) First, a brief lecture describing problem solving

2) This was followed by two ‘modelling’ videotapes; the first, from the WPA package with a London GP; and the second a locally made tape in Cantonese, showing the technique adapted to the local culture

3) We then did 3 role plays each; each role play had been adapted to the local culture and dealt with a different problem.

SIBERIA: Ekaterinburg

Training objectives in Ekaterinburg:

To set up a course to teach common mental health skills for primary care physicians

to train a GP tutor to take over the training after my visits stopped

to familiarise them with role-playing as a teaching method

To teach GP’s how to diagnose depression To teach them how to treat depression To teach them to deal with unexplained

somatic symptoms

After four visits to Ekaterinburg:

two GP tutors were now responsible for mental health training

The WPA videotapes were initially dubbed into Russian, but were finally replaced with locally made tapes, in Russian

By year 4, 75 physicians who had previously worked in polyclinics had been trained to become “family physicians”, and this included mental health skills

Assessment of training in Ekaterinburg:

“I never see depression in my practice”

– 50% before, 29% afterwards “depression is diagnosed only by the general

appearance” - 57% before, 18% afterwards “I now tell patients when I think they are depressed”

- 26% before, 60% after “I prescribe an antidepressant if they are depressed”

- 8% before, 40% afterwards “I give them a follow-up appointment”

- 47% before, 96% afterwards

The first 75 doctors trained: DEPRESSION

Assessment of training in Ekaterinburg:

“I never see M.U.S. in my practice” – 40% before, 18% afterwards

“I ask them about problems in their lives” - 37% before, 65% afterwards

“I assess them for depression” - 37% before,75% after

“I explain mechanisms distress -> symptoms” - 49% before, 68% afterwards

“I give them a follow-up appointment” - 53% before, 71% afterwards

The first 75 doctors trained:

MEDICALLY UNEXPLAINED SYMPTOMS

TANZANIA

VARIOUS TEACHING MATERIALS WERE DEMONSTRATED

Psychiatrists in training and nurses in Dar es Salaam

Three ways to role play: 1

The participants go into sets of three, and within each set there is

a doctor

a patient

and an observer

Ask a doctor to become their own most difficult patient. Get another doctor to interview him/her.

When the interview deadlocks (which it will!) ask them to give feedback; then get audience to suggest different ways of dealing with the patient.

Three ways to role play: 2

The participants go into sets of three, and within each set there is

a doctor

a patient

and an observer

For beginners, ask two doctors to become doctor and patient, telling the “patient” why they are attending, and give the doctor the information that must be conveyed.

Typical scenarios, breaking bad news, refusing a patient’s request

Three ways to role play: 3

The participants go into sets of three, and within each set there is

a doctor

a patient

and an observer

The participants go into sets of three, and within each set there is

a doctor

a patient

and an observer

If there are 3 role plays, it is important that each

members of the triad tries out each role once

It is not necessary for each doctor to practice each role play as the “doctor”.

They learn a lot from watching the others

The doctor

- is told what they knew about this patient before today, as well as what has been said until this point in the session.

In developed countries, the first of these in important – but it may not be in developing countries.

The purpose of this is to SAVE TIME during the role play

The patient

Is usually asked to be their own gender, and their own age.

They are told exactly what symptoms they have, that have caused them to seek care; and if necessary, what has happened up till now in the consultation.

They are sometimes told what they expect from the consultation, and what they think the problem is due to

The ObserverThis is a key role!

The observer MUST give feedback to the others at the end, about what they have seen.

They must be told exactly what they are looking for

TimingThe doctors often enter into it with enthusiasm, and have to be reminded that they are practicing only a small part of the interview

Stop role plays that are going on more than 5 or 6 minutes, as the Observer has not yet done their important part

The part with the observer must take at least as long as the enactment – this is when learning occurs

What the teachers do…Depends how many teachers there are, and how many doctors in the whole group.

Ideally, you should be watching only about 3 triads – so, 9 doctors. Fairly easy to see which triad is doing badly, and to eavesdrop

Try not to say much until afterwards however

Treating USS by “reattribution”

1) Feeling understood: patient feels doctor has understood his symptoms

2) Changing the attribution: the patient must “re-frame” symptoms - see them in a different way

3) Making the link: how emotion can cause the symptoms

Three stages:

Feeling understood

Take a full history, clarify complaintElicit associated symptomsRespond to mood cues, probe

mood stateExplore social & family factorsClarify health beliefsPerform a focused physical

examination

Changing the attribution

Feedback the results of physical examination & investigations

Acknowledge the reality of the patient’s symptoms

Reframe the patients complaints: remind them of other symptoms and life events

Making the link

• EXPLANATION: linked to depression or anxiety

• DEMONSTRATION: Practical; “here and now”; linked to life events

• IDENTIFICATION: other family members

• PROJECTION: family member - learned behaviour

Changing the attribution

Feedback the results of physical examination & investigations

Acknowledge the reality of the patient’s symptoms

Reframe the patients complaints: remind them of other symptoms and life events

During the role play

• 1)       Doctor must feedback the results of physical examination and CAT scan, and do this in a confident, reassuring way.

• 2)       Doctor must acknowledge reality of the patient’s pain, in a convincing way

• 3)       Doctor must remind the patient of the other symptoms, and get the patient to see that s/he has a whole set of problems, and that they started soon after the partner left.

What the observer must do:

1 Ask the doctor how s/he felt the interview went. What pleased him/her? Was there anything that could have been improved?

2 Ask the "patient" how s/he felt the problem was handled. After they have finished replying [if necessary] ask them what they liked; and what they disliked, about the way the doctor handled them

3 Give the doctor your own feedback, based upon your observations.

What we want you, the audience to do now:

• If you were the teacher, listening to this trio, would you wish to say anything that should be added to what you have either seen or heard?