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The Royal College of Psychiatrists Improving the lives of people with mental illness

Neuroscience in our Postgraduate Curriculum

highlighted human brain within skull

Changing a curriculum is like changing the direction of a supertanker. It moves very slowly, takes ages, but has to be done if you do not want to run aground. We feel it is time to update our postgraduate core training curriculum. Not all of it – 'if it ain’t broke don’t fix it' has always been a good mantra. But we feel that we are lagging behind in equipping the next generation with some of the new developments that have happened in neuroscience and are likely to impact on the profession of psychiatry during their lifetime. We are also unhappy with the relative neglect of some of the important physical health issues that afflict those with mental disorders, and which psychiatrists, who are of course doctors, ought to be well placed to address.

So our purpose is to ensure that the rapidly ongoing and exciting advances of basic and clinical neuroscience are made relevant and accessible to trainees, so that they are better equipped to deal with future developments in the diagnosis and treatment of adult mental health, neurodevelopmental and neurodegenerative disorders. We also expect that a suitably reformed training programme will have a positive impact on recruitment to psychiatry. There is evidence from the USA that increasing and modernising the neuroscientific component to residency training has resulted in an increase in graduates entering psychiatry training (see Insel 2015). I know it’s not a randomised controlled trial, but it certainly didn’t have a negative impact.

This direction of travel is consistent with two of my core positions as President – that we need to improve recruitment and retention of the best medical graduates into psychiatry, and we need to do more to take psychiatry back to the heart of medicine. These are really two sides of the same coin – the core message is that a speciality that can only recruit from medical students/junior doctors does itself no favours if it drifts away from them.

I am delighted that we have secured substantial funding for this process from the Wellcome Trust and the Gatsby Foundation. With this funding, we will be setting up a Commission that will review the current teaching of neuroscience in the specialist training of psychiatrists and will make recommendations for a new curriculum incorporating modern developments in clinical neuroscience. In so doing we are consciously following in the footsteps of the US National Neuroscience Curriculum Initiative (NNCI). We anticipate the process will take at least two years (partly because the subject is complex, but also so is the regulatory process – see note below). The project is beginning this month, with a lecture by Dr Jeff Lieberman who will fly over from the United States specially to talk at the College on 20 April – more details here if you’re interested in coming.

It is gratifying to note the positive reactions that we have already received, especially from trainees. But does this mean that we are moving towards a more “medical model” of psychiatry? Categorically not. Frankly I hate the word “medical model” anyway. The reason is that when I hear it used by our critics I know that all too often they have in mind a caricature of modern psychiatry, usually coming from too much exposure to repeats of One Flew Over the Cuckoo’s Nest. And very soon I know that the room will be full of the smoke from a long line of burning strawmen. As I never tire of saying – psychiatry depends on the integration of the physical, psychological and social. Take any one of those away and what you are left with is not psychiatry. What we are seeking to do in this project is update the first mentioned, not diminish the second or third.

So let me restate in no uncertain terms that our curriculum, our clinical care and indeed our profession as a whole remains embedded with what it is that makes psychiatry different, rewarding and successful – namely the integration of the physical, psychological and social into everything that we do. Our curriculum may need to change, but that underlying principle never will.


Note: The General Medical Council (GMC) has overall responsibility for regulation of postgraduate medical training. In this role they approve the curricula and assessment systems. The curriculum is defined by the GMC as a statement of the intended aims and objectives, content, experiences, outcomes and processes of a programme, including a description of the structure and expected methods of learning, teaching, feedback and supervision. The GMC requires that the curriculum should set out what knowledge, skills and behaviours the trainee will achieve. The College also has a responsibility for and ownership of the curriculum and assessment system. Changes to the curriculum are generated within the College and then sent to the GMC for approval. Deaneries and local education providers have responsibility for the delivery of the programmes including workplace-based experience based on the approved curriculum and assessment system.

Any change to the curriculum must therefore be generated by the College, approved by the GMC and delivered by the Deaneries and local education providers. Delivery of a meaningful change will require involvement and sign up from all parties.

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Comments

Re: Neuroscience in our Postgr
I agree very much Simon on expanding the neuroscience portion of the curriculum; in any case it leads to more examinable and un-arguable MCQ's!

A good start would be to have mandatory annual training on sleep disorders, as it is for neurology trainees. As you (and Dr Lieberman) knows the current hot topic is patterns of neuronal pruning and associated compliment / microglia activity; again trainees need to know this stuff.

HOWEVER, can I suggest we still have a lot of attitude stuff to learn? Rather than the College motto of 'Let wisdom guide' (based on Plato I think) could we change this to Primum Benificum (Let kindness guide) or Benificum via Consilium (Kindness guiding wisdom)?

If, as psychiatrists, we think we are best qualified to generate wisdom (compared to our patients, carers and referrers), we will constantly move from one mistake after the other - think of the defeat depression campaign, CTOs and arguably parity of esteem. It now looks as if our much trumpeted £4 billion was on the back of disability benefit cuts; so we might not get the money anyway in 2020.
Re: Neuroscience in our Postgr
If you want psychiatry to survive this approach should be supported because developments in neuroscience threaten to squeeze psychiatry into oblivion - sandwiched between neurology and clinical psychology. However, does it need to survive ? Perhaps history will show it fulfilled a temporary holding role while the professions of neurology and psychology expanded to their natural potential ?
Re: Neuroscience in our Postgr
Finally! I hope this leads to more integrated neurosciences training for all in the files of not just psychiatry but also neurology and neurosurgery. I have always been of the opinion that unless we provide such integrated training we are not just going to lag behind in our own professional training but failing our patients as well. We will be moving in the right direction if we are able to organise this well. I welcome this initiative. Better late than never! I also feel that we need to include basic medical training as well and not just neuroscience. A good medical foundation is also the need for improved patient care, especially when we are acutely aware of the physical health problems of our patients. I think a programme should be rolled out for Consultants to update their neurosciences skills as well and this should be supported through college initiative like the ones thought for the trainees.
Re: Neuroscience in our Postgr
The role and utility of neuroscience within psychiatry should certainly be a topic discussed within this new curriculum. What it brings to the table (such as colourful brain scans) and what it cannot provide (such as the causes and meaning of our mental afflictions).
Re: Neuroscience in our Postgr
Great to have the neuroscience curriculum updated, but do you feel it is only this part of the curriculum that deserves attention? I wonder if others would agree that updating other aspects of the curriculum might support psychiatrists to do more to integrate the psychological and social?
Re: Neuroscience in our Postgr
I suggest reading "Brain on Fire" by Susannha Cahalan to see why moving in this direction is better th necessary and exciting!
Re: Neuroscience in our Postgr
Simon, can I add these 2 to my previous comments please? I am thinking of issues bridging neuroscience and attitudinal training needs. I hope Wendy Burn is picking up on this very helpful blog discussion above.

1. Practitioners of neuroscience (mainly neurologists) think of symptoms and signs in terms of localisation in the brain; Psychiatrists are trained to think in terms of a-priori classification of symptoms and behaviour. It is my opinion that the attempt to localise site helps in 2 ways; firstly it reduces the tendency to be judgemental and secondly it is more likely to pick up medically (and sometimes psychiatrically) unexplained symptoms which seem to originate from multiple, often poorly connected sites in the brain (as shown by PET studies carried out by the late Sean Spence in Sheffield). So learning about neuroscience involves an attitudinal change towards localisation firstly, and ignoring traditional psychiatric classification.
2. The other issue is the common neuropsychiatric conditions with delayed diagnosis such as Autism (apparently delayed by an average of 4 years), ADHD (especially in adults) and arguably, psychosis, including post natal psychosis, in women. Again this could be a problem with drilling down on specific symptoms or behaviours to satisfy the classification system, rather than seeing the picture as a whole (often presenting in a bitty form initially). Our self imposed limitations of patient confidentiality can sometimes blind us to what family and outsiders think are the key problems. The lack of settled in patient observational time is also a limitation, and we don’t use smart phone recordings of behaviour anywhere near what is possible (unlike neurologists who routinely request recordings when dealing with seizure activity).
Re: Neuroscience in our Postgr
American Psychiatry got critised for labelling the 90s as the decade of the brain, debate still rages whether psychiatry will survive as a speciality but if one remembers that mind is a function of the brain, it is imperative that we know the brain better. Advances in neuroimaging, genetics and epigenetics, molecular biology makes it necessary for current and future trainees to learn about how the final common pathway of abnormalities in brain functions manifest as mental disorder. Well done Mr President.
Re: Neuroscience in our Postgr
I am delighted to see this curriculum development. I have become personally very interested in the neuroimmunology developments and these are barely touched upon in the current curriculum. I have had two patients presenting with classic features of psychiatric disorder, ultimately we seem to rely on neurologists ordering the relevant simple blood tests on our behalf. Our range of treatments is limited and it is only by deepening our understanding of the multifactoral components in the development of psychiatric disorder that we will start to widen our therapeutic interventions. Neuroscience is rapidly developing and really quite exciting, we need to be embracing this and actively looking at how this applies to our field of medicine.
I do however agree with some of the above comments, adding without subtraction will mean a bloated curriculum without attached prioritisation. Many elements of the curriculum (at least that are tested and posed as exam questions) are historical and 'of interest' at best rather than having direct relevance to practice. It would be a very positive move by the college to look now at the whole curriculum and make revisions.
Re: Neuroscience in our Postgr
I think this review is timely. Role diffusion, both within and outside medicine, is changing the role and relevance of psychiatry. GPs, paediatricians and neurologists have broadened their approach and disciplines, such as psychology and nursing, have extended their reach. Training and experience have come to outweigh traditional in determining what people do.
I think we have to be able to define what advantage might come from a medical training, one of our remaining, major distinctions from psychology. The MRCP has become a diversion in the psychiatric training path. It might be useful therefore to rehearse the arguments why someone, keen to work in this field, should go the time and expense of gaining a medical degree. The trick will be to imagine the landscape in twenty years’ time rather than as it is now.
Re: Neuroscience in our Postgr
Great news and a long time coming.
Re: Neuroscience in our Postgr
As a service user I'd like to see the work around neurobiology, development, trauma, dissociation, shame and compassion better understood by doctors and also the ability to explain relevant details to patients.

Additionally it would indeed be incredibly helpful if psychiatrists were able to refer to specialists for physical problems or proactively identify those who may have physical conditions requiring assessment and management. The severity of these conditions may not be high in isolation but can still have a huge impact on quality of life in combination with mental health difficulties. Very pleased to see this mentioned above and to see investment in neuroscience training.

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Professor Sir Simon Wessely

   

Professor Sir Simon Wessely

President


Sir Simon Wessely is Regius Professor of Psychiatry and Co-Director King’s Centre for Military Health Research and Academic Department of Military Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.  He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes. 

He has responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.

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