Psychiatry training for medical students: A global perspective and implications for India’s competency-based medical education curriculum

Abstract

Competency-based medical education curriculum (CBME) has received traction worldwide. However, its adoption and implementation have significantly varied across the globe. The National Medical Commission, India (2019) has adopted CBME to improve the quality and content of training of medical students. However, the ongoing COVID-19 pandemic has spawned several challenges implementing the CBME. Therefore, there is a need to reflect on using novel teaching and assessment methods to enrich medical and psychiatric training. In this paper, we aimed to study global trends and characteristics of competency-based psychiatry training programs and how these experiences can be utilized to overcome challenges and facilitate the implementation of CBME in Psychiatry in the Indian context. A literature search was conducted using PubMed and Google Scholar databases. The findings are presented narratively. Psychiatry training for medical students greatly vary across the globe. High-income countries mainly have implemented CBME and have incorporated psychiatry training during the foundation/pre-clerkship period itself. There is more reliance on skill development and flexible and learning-based training vs. time-based training. Various enrichment activities have been incorporated into the medical curriculum to promote and strengthen psychiatry training for medical students, particularly in developed nations, which have yielded positive results. Although the COVID-19 pandemic has adversely affected the medical student’s training, it has reiterated the significance of skill-based education and opened novel avenues for implementing the CBME.Medical educationists need to adapt themselves to provide CBME to the students. Making structural, curricular changes, orienting teachers, and students about the CBME, mentoring teachers, adopting novel training and assessment methods, utilizing enrichment activities, collaborating with educational institutions and technology providers, periodically evaluating the implementation of the CBME, and making appropriate course corrections are essential. In addition, there is a need to address structural barriers, such as lack of workforce, for better realization of the CBME objectives.eriodically evaluating the implementation of the CBME, and making appropriate course corrections are essential. Additionally, there is a need to address structural barriers, such as lack of workforce, for better realization of the CBME objectives.

INTRODUCTION

Medical education has undergone significant transformation over the years across the world. There has been traction towards competency-based medical education (CBME). Although high-income countries (HICs), such as United States, Canada, United Kingdom, Australia, etc., have been practicing it for two to three decades, low- and middle-income countries (LMICs), such as India, China, Turkey, etc., have also acknowledged and variably adopted it in their medical curriculum.[1,2,3,4] CBME works under the framework of an integrative model of teaching, student-driven learning, and skill- or competency-based (vs time-limited) learning and assessment.[5,6,7,8]

The key attributes of CBME are producing medical undergraduates (henceforth medical students) who are skilled in providing holistic care to the patients (based on the needs of the society) that are culturally sensitive. Furthermore, it emphasizes value-based training and promotes attitude, ethics, and communication (AETCOM) skills while delivering clinical services to society.[6,9,10] Also, novel assessment methods (both formative and summative), including entrustable professional activities (EPAs) and training of the teachers, are also essential components of CBME.[11,12,13]

Following global trends, the National Medical Commission (NMC) of India launched CBME in 2019 to enable Indian medical graduates provide preventive, promotive, curative, palliative, and holistic health care with compassion and excellence.[6]

Globally, though CBME is increasingly being adopted to enhance the training and quality of medical students, its implementation has been marred by several challenges, particularly in resource-poor countries (LMICs). Furthermore, the ongoing COVID-19 pandemic has also spawned several challenges (for medical educationists, teachers, and students) in realizing the CBME. Simultaneously, it has emphasized the significance of CBME in the current scenario and how novel teaching and assessment methods can be utilized to enrich medical training.[14,15,16]

The importance of psychiatry training, including acquiring these skills to better deal with the patients’ psychosocial aspects and develop into better professionals, has been increasingly recognized by the administration or medical educationists throughout the world.[6,7,9,17] Various attempts have been made to improve the psychiatry training of medical students through CBME. It includes increasing the duration of training in psychiatry, integrating it with other disciplines, early exposure of students to the concepts and clinical utility of psychiatry, and organizing various enrichment activities with positive outcomes.[5,10,18,19] For instance, under NMC 2019, topics related to psychiatry are covered under 19 topics and 117 competencies. The duration of psychiatry training has been increased to 40 hours of lectures, 4 weeks of clinical rotation, and 2 weeks of mandatory internship. Despite the above positive changes in psychiatry training, psychiatry is still not the main subject—instead considered a sub-specialty under general medicine.[8]

Quality training in psychiatry can facilitate medical students in achieving goals and objectives of CBME (as envisaged in various medical curriculum frameworks such as NMC 2019). For example, the competencies learned via CBME facilitate holistic care to patients of any discipline, particularly while dealing with chronic medical illnesses, which can be better learned with quality training in psychiatry. Furthermore, behavioral sciences’ integration (vertical and horizontal) with other disciplines can facilitate the students’ learning, a practice commonly followed in HICs.[19,20] Similarly, early clinical exposure to psychiatry can help students get oriented to it and learn essential competencies at the earlier stages of their education that could be practiced throughout the undergraduate program.

Despite substantial literature on the area of psychiatry training in medical education, it has not been systematically reviewed. Such a review would provide valuable insights into global patterns of psychiatry training under the undergraduate medical curriculum, including various enrichment programs or activities, challenges, and opportunities in implementing CBME, particularly in a LMIC like India. The last such review was done more than a decade ago.[21] Since then, much has changed; this warrants a reevaluation to identify current global best practices of teaching–learning (T-L) approaches and curriculum delivery. Challenges to T-L activities posed by the ongoing COVID-19 pandemic provide additional context to this effort. This paper reviews global trends in psychiatry training, including various enrichment activities, their strengths and weaknesses, and how these experiences can be utilized in implementing CBME in psychiatry in the Indian context.

MATERIAL AND METHODS

A literature review was conducted by going through PubMed and Google Scholar databases with the key terms “medical education”, “medical curriculum”, “CBME”, “undergraduate”, “medical student” (for medical education) and “psychiatry training”, “teaching”, “enrichment program”, “curriculum” (for psychiatry training) [Supplementary File 1]. Bibliographical and grey literature searches were also performed to obtain the medical curriculum and psychiatry training curricula, including various enrichment activities in psychiatry across the globe. An attempt was made to provide data from at least one country of different WHO regions, including obtaining data from the prestigious universities of that country by visiting their websites.[22] Findings have been categorized region-wise and discussed in line with the World Bank’s income group.[23] Since the focus of the current review is on undergraduates (medical student henceforth) psychiatry training, literature solely focusing on postgraduate psychiatry training or residency or fellowship programs was excluded. The findings have been described narratively.

FINDINGS

Concept of CBME, its history, and the context of its evolution

Competency refers to the ability to do something successfully and effectively. The aim of imparting medical education is to make medical graduates skilled enough to effectively cater to society’s needs. However, traditional medical undergraduate (UG) teaching was geared towards knowledge acquisition and had a time-based learning approach; furthermore, effective assessment tools to measure the competencies of the medical students were lacking. In contrast, CBME emphasizes a skill-based and learner-centric approach and includes provisions for adequate assessment of the competencies, including workplace-based assessment.[24]

Globally, CBME programs have been implemented in a few developed nations earlier than India. For instance, the Accreditation Council for Graduate Medical Education (ACGME) of United States, in 2001, emphasized the educational outcomes in terms of competencies to be achieved during the medical course. Furthermore, through the Milestones Project of 2007, various “milestones” were identified along the way to becoming a trained doctor, and ways of assessing those competencies were also laid down. This further strengthened CBME in the United States. Likewise, the “Tomorrow’s Doctors” framework of General Medical Council (United Kingdom) in 1993 defined outcomes and standards of graduate medical education. Similarly, nearly three decades ago, the Royal College of Physicians and Surgeons of Canada outlined the CanMEDs framework to implement CBME.[25]

In India, the forerunners of CBME can be traced to the Graduate Medical Education Regulations (GMER), 1997 of the erstwhile Medical Council of India (MCI). This document envisioned CBME; however, competence was mentioned under institutional goals and not defined. Subsequently, the Vision 2015 Document, launched in 2011, emphasized competency as a desirable outcome of Indian medical graduate training so that graduates could effectively meet the health care needs of the society they serves. However, the assessment part was overlooked in this guiding document.[25]

Subsequently, in the GMER 2012, CBME was expounded in a more detailed manner and various subject-wise competencies were outlined; however, the alignment of the assessment methods with these competencies remained elusive. Following several rounds of discussions and reviews, under the newly formed NMC, CBME was formally introduced in the country in August 2019. Notably, various T-L methods have been described in greater detail here, including EPAs for assessment and the role of faculty development in the implementation of CBME. The document recognizes the role of psychiatry training of UGs in realizing the goals of CBME, especially the learning of soft professional skills described in the AETCOM module.[24,25]

The essence of CBME

CBME aims at imparting knowledge, skills, values, and attitudes (KSVA) among medical students. The key areas of learning involve patient care, medical knowledge, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism.[25,26] It describes five key qualities of an Indian medical graduate: clinician, leader and team member, communicator, lifelong learner, and professional.[10,27]

Furthermore, CBME emphasizes skill acquisition and a milestone-based assessment as essential components of it. The latter is realized through various EPAs representing discrete units of clinical work that can be entrusted to a medical trainee with decreasing intensity of supervision. It involves the Knowledge, skills, and attitudes necessary to carry out the respective clinical work.[26] In psychiatry, one of the EPAs could be diagnosing bipolar affective disorder in a patient, differentiating it from other possible diagnoses (e.g., schizoaffective disorders and borderline personality disorders), psychoeducation of family members about the illness, pre-lithium workup, and relapse prevention.

Furthermore, milestone-based EPAs have been practiced under the CBME curricula of various international medical education systems (ACGME, US; CanMEDS framework; Royal Australian and New Zealand College of Psychiatrists (RANZCP)). Specifically, under the milestone project in the US, psychiatry-specific EPAs such as establishing therapeutic alliances in challenging situations, exploring, and dealing with suicidality, and handling ethical problems in complex clinical situations have been described.

National medical commissions’ efforts to improve psychiatry training under CBME

As highlighted above, the NMC (India) has attempted to implement competency-based medical education in psychiatry; a total of 19 topics and 117 competencies related to mental health have been listed in the curriculum document. Notably, the significance of learning skills related to patient–doctor relationships, holistic patient care, and ethical and legal mindsets while caring for persons with mental illness have been acknowledged.[28] Integrating psychiatry with various disciplines (vertical or horizontal integration) has been a welcome move, particularly highlighting the significance of psychiatry in general health care and reducing the stigma attached to psychiatry. Furthermore, patient–doctor relationships and common psychiatric disorders have been identified as core competencies that a medical student should be able to know or demonstrate under different clinical circumstances. Additionally, EPAs have been designed for various competencies with varying levels of knowledge or skill acquisition: K – Knows, KH - Knows how, SH - Shows how, and P - performs independently. Interestingly, none of the procedures under psychiatry are mandated to be done independently for certification or graduation.[28] Skills such as administering parenteral medications or sedatives and breaking bad news is not included though they could have been a valuable addition to the curriculum.

Comparison of medical curriculum for medical students between high-income and low- and middle-income-countries

We found that medical curriculum and training for medical students vary across the world. CBME and robust assessment systems have been promoted and implemented throughout the world.[1,4,8] Furthermore, there has been a perceived need that students should be exposed to psychiatry training or teaching at earlier stages (foundation/pre-clerkship/pre-clinical years) to realize the aptitude mentioned above and skills.[19,20,29]

Similarly, psychiatry training has been variably integrated (vertically and horizontally) with other disciplines of medicine either through system-wise teaching or multidisciplinary training. For instance, some HICs, such as the US, UK, Australia, Canada, etc., have kept psychiatry as a major subject in their medical curriculum.[3,4,30] Moreover, they emphasize problem-based training and student-driven learning (providing autonomous conditions that motivate learning) under the supervision of the tutor or psychiatric consultant. Their training heavily involves teaching in small groups (SGs), summer courses or projects, and exposure to sub-specialties (particularly child and adolescent mental health, substance use sisorders, forensic psychiatry, etc.).

Furthermore, they have provision of periodic formative (workplace-based assessment, mid-in-rotation training assessment (ITA), etc.), summative assessments (EPAs and End-of-Rotation ITA), and elective training.[19,20,31,32] For instance, under the RANZCP fellowship program, various formative and summative EPAs have been designed to assess milestones in training, including workplace-based assessment. The stage-wise summative external evaluations include multiple-choice questions (MCQs), essay writing (earlier stages of the course), objective structured clinical examinations (OSCEs) (middle-stage), a scholarly project, and psychotherapy case management notes (later stages, including in psychiatry subspecialties).[10,26,27] Similarly, the EPAs are assessed based on the stage of the trainee: stage 1, two mandatory adult psychiatry case workups; stage 1 or 2, adult psychotherapies; stage 3, case workups from psychiatric subspecialties (consultation–liaison/child, adolescent psychiatry, addiction-medicine, forensic psychiatry, etc.); and stage 4, two EPAs from each of the previous stages.

Likewise, in the US, CBME has been widely implemented. For instance, at Trinity School of Medicine, exposure to psychiatry starts from the very foundation or pre-clerkship years. It has allotted credit scores provided after a medical student successfully completes the term and has been assessed through various formative and summative assessments. The psychiatry exposure includes lectures on early human development, personality aspects (term 1), behavioral sciences involving the bio-psycho-social model of medicine, neuro-cognitive functions, ethics, and legality in treatment (term 4), and basics of knowledge, communication skills, and professionalism (term 5). The curriculum involves six weeks of clerkship with exposure to psychiatric interviewing skills, rapport building, and case formulations based on the bio-psycho-social model of psychiatric illness.[33] Moreover, there is a provision for 27 weeks of electives in different disciplines, including psychiatry. This elective exposure may subsequently drive greater student enrollment in the residency program of their respective discipline.

The duration of psychiatry training, both in terms of theory (lectures/seminars, case discussions, etc., at the foundation years/pre-clerkship or throughout the course) as well as clinical attachments (6–12 weeks) are considerably longer compared to most medical schools in LMICs [Table 1]. In contrast, the training in psychiatry is less enriched in LMICs. For instance, in Bangladesh, the duration of a theory class (that is too didactic) is only 20 hours, while the duration of a clerkship in psychiatry is only three weeks; moreover, an internship in psychiatry is not mandatory. Similarly, in countries like India, Bangladesh, and Nepal, training in psychiatry starts from or later than the third year of the medical course. Barring Sri Lanka and Japan, psychiatry is not a major subject in most countries of the south-east Asian region-WHO (SEAR-WHO).[1] Similarly, psychiatry’s weightage in the residency program’s entrance exam in these counties is abysmally low (comprising 1%–1.5% of total marks).[2,21]

Table 1.

Medical curriculum and psychiatry training of medical students across the world^$

Country (regulatory body)	Undergraduate medical curriculum	Psychiatry training	Strength or Remark
WHO-region: America
United States (Accreditation Council for Graduate Medical Education (ACGME))[33,34]	Program name: MD Duration: 4 years Pre-clerkship: 2 years Clerkship: 2 years	Pre-clerkship: early human development (term 1), behavioral science with a focus on knowledge, communication, professionalism (term 4). Clerkship: 6 weeks in psychiatry, a major subject; Provision of elective clerkship, including in psychiatry.	Integrative program Emphasis on supervised training Option for electives Teaching in a small group (SG) Summer courses, and research with credits Exposure to diverse settings (CAAMH, community, CL, forensic, old age psychiatry, etc.) Enrichment programs
Canada[35](CanMEDs, 2015) framework governs the standard of medical education)	Only graduate-entry program Duration: 4 years; First 2 years (foundations): basic science; Year 1: cognitive sciences; Year 2: chronic disease mgt., incl. mental health; Year 3 and 4: clerkship, incl. electives	Around 8,000 hours of teaching per year at the MD Program Pre-clerkship: 3 weeks psychiatric rotation Clerkship: 6 weeks. Elective options in psychiatry. Exposure to CAMH, geriatric psychiatry, addiction medicine	System-based curriculum Provision of joint degree programs; a limited number of interested students can simultaneously enroll in MSc/Ph.D. programs; research opportunities during electives. Case-based learning, multidisciplinary summary lecture, SG teaching
WHO-region: Europe
United Kingdom (General Medical Council (GMC))[36,37]	Course duration: 6 years First two years: pre-clinical Year 3-5: clinical posting Year 6: one year of foundation course (internship)	First two years: medical psychology Year 3–5: 8 weeks clinical attachment in psychiatry Year 6: elective posting (10-week elective, student assistantship)	Integrated approach Provision of student-selected components (SSCs): opportunity to pursue a subject of interest Classes in SGs Problem-focused learning Opportunity to be exposed to CL and forensic psychiatry, including mental health act, etc. Enrichment programs
Spain[38]	Course duration: 6 years, Preclinical: 3 years Clinical: next 3 years	Second semester: psychological medicine (6 credits) Year 4: psychiatric attachment (6 credits)	Enrichment program- Innovative Teaching Plan
WHO-region: Mediterranean region
Turkey# (National Core Curriculum)[39]	Course duration: 6 years, including one year of internship	Year 5: Lecture in psychiatry Duration: 40 hours of lectures, 10 hours of clinical training 20 days: Psychiatry rotation (3d in CAMH) mandatory exam at the end of the posting Internship: 1 month of clinical attachment.	Internship in psychiatry is less robust considering a higher students to faculty ratio. Psychiatry receives lesser weightage in entrance exams for postgraduation.
WHO-region: Africa
Somaliland#[40]	Course duration: 5 years	Year 5: 20 weeks psychiatry teaching; 16 weeks of bed-side teaching (twice/week). Lecture throughout the psychiatry posting. 2 weeks: Theory lecture in global mental health -Interested students have the opportunity to participate in community outreach Assessment: mid-term- and final exam	Alumni driven program Hybrid mode of teaching during the COVID-19 pandemic
Botswana#[41]	Course duration: 5 years	Regular training, incl. one long-term on-the-job training. Clerkship: 8 weeks rotation; for completion, mandatory passing of exam in psychiatry	Collaboration with UK and US Problem-based learning Innovation in imparting psychiatric training (high-tech and low-tech tools for learning clinical and theoretical aspects) Limited resources paved way for evidence-based and reality-oriented training (investigation and treatment).
WHO-region: Asia
India#[6]	Course duration: 5.5 years, incl. one year of internship.	-First year: Basics of behavioral science -Year 2: clinical posting -Year 3 and 4: lectures in psychiatry -Psychiatry training: 40 hours of theory and 4 weeks of clinical postings. Assessments: Formative and summative -Internship: 2 weeks of psychiatry rotation.	-Psychiatry is still a subspecialty under general medicine -Integrative teaching has been adopted. -Psychiatry is not a major subject; recently AIIMS, Rishikesh has made this provision. -Variation in training across countries, incl in INIs.
Sri Lanka# (Sri Lanka Medical Council)[1]	Course duration: 6 years, incl. one year of internship.	-8–12 weeks of clinical training and 40–75 hours of lectures Clinical posting: two separate clerkships placed in the 4th and 5th year. Internship: Psychiatry posting isn’t mandatory	-Psychiatry is one of the major subjects like medicine, surgery, etc. -Considerable homogeneity in training across the country compared to other SEAR countries
Bangladesh#[1]	Duration: 6 years incl. one year of internship	3-weeks of clinical rotation in psychiatry Year 4 and 5: Ward placement in the third phase for clinical classes 20 hours: didactic lecture Internship: no mandatory placement in psychiatry	-Psychiatry teaching starts late in medical course -Receives less importance during the internship (elective psychiatry posting)
China# (Clinical medicine curriculum)[42]	Course duration: 6 years	-Year 3–6: Didactic lecture and clinical attachment -Year 6: 7 weeks clinical clerkship -Exposure to in-patient, out-patient, and community rehabilitation clinics. Exposure to sub-specialties: geriatric, CAMH, SUD, and sub-specialty electives	Variation across the country Japan#
(Japan Accreditation Council for Medical Education (JACME))[43]	Duration: 4–5 years Pre-clinical: 2 years Clinical: 2 years school, and college entry programs (duration: 4 years)	2 weeks psychiatry clerkship -Psychiatry, one out of six major disciplines	Emphasis on outcome-based education
WHO-region: Oceania
Australia and New Zealand (Australian Medical Council (AMC); Medical Council of New Zealand) e.g.,[44,45]	Duration: 4–6 years Year 1: background knowledge of biomedical science Year 2–3: clinical attachment Year 4: electives or selective pre-vocational training: 2 years	-Taught throughout the undergraduate course -Year 1: Lectures on mental health -Proposal to increase rotation in psychiatry to 13 weeks (Victoria mental health system, 2021)	-Emphasis on problem-focused learning and Integrative learning -Assessment: throughout the program, fit for purpose assessment -Culturally relevant training -Interdisciplinary and interprofessional training. -Small group teaching -High-tech simulation facilities

^#Low-and middle-income country, the rest others are HICs. (): mentions the accreditation body/agency; AIIMS: All India Institute of Medical Sciences, INIs: Institute of National Importance; CAMH: Child and adolescent psychiatry, CAAP: Combined accelerated psychiatry program (CAPP), CL: Consultation-liaison, mgt: management, INIs: Onstitute of national importance, SEAR: Aouth-east Asian, region, SG: small group, SUD: Substance use disorders

Fortunately, many LMICs, including India, with their movement toward CBME, have increased the duration of psychiatry training (at least 40 hours of teaching and around 4 weeks of clinical rotations) for medical students and have recognized that training in psychiatry would inculcate effective soft skills among the students and promote holistic care for the patients during the former’s interaction with the latter in other disciplines.[6]

Enrichment activities in psychiatry training across the world:

To provide effective training in psychiatry and orient students about various aspects of psychiatry, including reducing the stigma and myths related to psychiatry and making them aware of its scope, many universities, particularly in HICs, are offering such programs or courses for interested students. These include the combined accelerated program in psychiatry (CAAP), University of Maryland (US)[19]; psychiatry early experience program (PEEP), and single-day enrichment activities in forensic psychiatry at King’s College and Oxford University, Imperial College, respectively (UK); innovative teaching plan (ITP), University of Zaragoza, Spain[11,20,29]; Psychiatry Institute for Medical Students program (PIMS Program), Toronto (Canada)[31]; Claassen Institute of Psychiatry for Medical Students, University of Western Australia,[10,27] etc. Likewise, some of the LMICs such as China (psychiatry major curriculum (PMC))[42] and Somaliland, Africa (collaborating with the universities of UK and US and involving a hybrid model of training with international teachers on board) have come up with innovative strategies to enrich their psychiatry training [Table 2].[16,41]

Table 2.

Enrichment programs in psychiatry training worldwide and their effectiveness

Program name (Country)	Key component	Type of study and evidence	Critique
Combined Accelerated Program in Psychiatry (CAAP) University of Maryland (US),[19]	-Duration: 4 years -Freshmanship (year 1) Assimilation of basic psychiatric concept. -Clinical skills semester 1.: Closed-circuit TV for observation -Semester 2: signs/symptoms in psychiatry, MSE (n=5 recording), psychodynamic interview. -Summer course: 8 weeks -Sophomore year (year 2): individual psychotherapy for 5 years (1 male and 1 female patient) with periodic supervision. -5 months: rotation in pediatrics and CAMH (therapy for one child and one family) -Provision of elective with credits, -6 months community psychiatry posting. -Critical sense development.: monthly lunch with consultants, mandatory research work to graduate.	-Study type: Cross-sectional observational study, -Results: CAPP trainees in year 3 fared better than non-CAPP medical students and year 2 psychiatry residents.	-Early career choice may restrict exploration -Early clinical exposure may lead to later withdrawal/skipping routine postings -Greater pampering -Greater personal attention -Discrimination towards non-CAPP residents -Better performance could be due to greater time and attention devoted to the CAPP-trainees -Difficult to replicate in the low-resource country like LMIC
Psychiatry Early Experience Program (PEEP), Kings College, London (UK)[20]	-Exposure to psychiatry specialist in the first year (pre-clerkship) itself (vs in year 3 traditionally). -Shadow their doctor (trainee residents) two days every six months throughout the 5 years of medical school. -Pre-clerkship: PEEP focuses on interactions between students and residents.	-Study type: Longitudinal -Results: Sustained improvement in mean ATP-30 scores -No significant difference between baseline specialty choice and specialty choice at three-year follow-up. Qualitative data suggests relevance of psychiatry in other disciplines of medicine.	-PEEP has the potential to improve recruitment into psychiatry. -Not clear whether PEEP is most effective to select participants (based on an established commitment to psychiatry) or to try to influence undergraduates who have not decided on their career choice.
Psychiatry Institute for Medical Students (PIMS), University of Toronto (Canada)[31]	-Duration: Week-long -The phase of course: Pre-clerkship -Components: Each day a thematic focus Morning hrs: informal lectures/seminars Afternoon: clinical electives; also observe ECT; patients-panel discussion1 Social activities: weeks begin with an orientation about the program, interaction with psychiatry trainees and staff of the institute.	-Study design: Pre-post -Significant in the proportion of the students interested in pursuing psychiatry as a career and decline in undecidedness in pursuing psychiatry as a career. -Students’ highly rated program as enjoying, organized, and relevant. 43% of attendees matched to psychiatry residency courses. 53% applied for a residency program.	-
Claassen Institute of Psychiatry for Medical (CIPM), University of Western Australia (UWA) (Australia)[32]	-Duration: one week -Phase, clinical stage -Components: Morning interactive seminars; afternoon visit to community MH clinic and hospital psychiatry setting; week-long discussion about psychiatric specialties, case studies discussion, and contemporary issues. Informal meeting during lunch with the consultant; mid-week dinner with discussion on the scope of psychiatry; feedback of student, student-led debate on the contemporary issues in psychiatry2 coordinated by the psychiatry registrar	-Study design: -Pre-post number of students who are definitely considering a psych. career increased from 57% to 77%. -Knowledge about various areas of psychiatry (forensic psychiatry, mood disorders, etc.) improved significantly. -Significant interest in the student-led debates and stigma workshop. -A considerable proportion of the attendees took psychiatry as a residency course and a sizeable proportion of interns considered psychiatry as a career	-Target population: Students interested in psychiatry, yet not committed to pursuing psychiatry as a career. -Promoted psychiatry as a career
Innovative teaching plan (ITP), University of Zaragoza (Spain)[11]	-One full year of academic course -Two hours/week lectures, seminars Weekly sessions with the ITP student-leaders SG (n=4) with ITP leaders in seminars. -One research project by SG and ITP student-leader. -Bedside teaching: Tutors and personalized supervision, systematic meeting with the students, annual dossier by the coordinator, one-to-one supervision by the psychiatry faculty during clerkship, voluntary, summer clinical practices for students.	-Study design: Pre-post -Result: Satisfaction was rated high or very high” on Outcome measure: Medical teaching quality questionnaire incl. the usefulness of the course for physicians, the quality of methods of teaching, and the bedside teaching. -The majority reports satisfaction with the SG discussion. -Yearly evaluation and feedback systems also were found useful in suitably modifying the self-teaching methods. -Positive evaluations of teachers by students; promoted research mind.	-Intended to train student leaders in SGs teaching to fellow students -Challenge in replicating in LMIC where faculties are overburdened, therefore, devoting time particularly in bedside teaching, research, etc., may not be feasible.
Psychiatry major curriculum (PMC) (China)[42]	-Course duration: 5 years -Didactic lecture and patient exposure: throughout. -Year 1 and year 2: outreach program -Year 3 and year 4: 84 hours of patient demonstration. -Year 5: 16 weeks of clerkship, 12 hours and 4 hours each of lectures and clinical exposure in CAMH and SUD respectively. -Electives in community rehabilitation psychiatry, subspecialty electives	-Research design: a review paper. -More comprehensive exposure in psychiatry -Greater pre-clinical and clerkship course hours -Greater diversity in exposures to setting and sub-specialties	-

^$List is not exhaustive, considers those countries whose data emerged on literature search ATP-30: Attitude Towards Psychiatry, devlp: Development, ECT: Electro-convulsive therapy, MH: Mental health, MSE: Mental state examination, LMIC: Low- and middle-income country, comm. rehab: community rehabilitation, SG: Small group, TV: Television. ¹treatment experience, stigma, occupation, family life, employment, etc.; ²stigma, coercive treatment

Salient features of various enrichment activities

• Targeting students who are interested in psychiatry or are undecided about their choices.

• Early exposure to psychiatry during their medical program (during freshman year in CAPP; two days or semester for five years in PEEP; pre-clerkship period, PIMS program, etc.).

• Supervised training in the clinical aspects of psychiatry such as psychotherapy, CAMH, family therapy, electroconvulsive therapy (PIMS Program), etc.

• Provision of summer courses or projects with micro-credits.

• Training in SGs (in all enrichment programs), including student leader–driven discussions or debates on contemporary issues (CIMS, Australia; ITP, Spain).

• Research work including mandatory research activities in a SG (CIPM, Australia; ITP, Spain) or individually (University of Maryland, US).

• Provision of electives and special credits upon completing the program (University of Maryland, US).

• Greater interaction with psychiatry trainees or residents (PEEP and one-day enrichment program in the forensic psychiatry, UK; CIPM, Australia).

• Regular personalized and supervised training with periodic assessments, including submitting the annual dossier on the students’ performance (University of Maryland).

• Critical sense development through personalized interaction, informal social activities, lunches or dinners, etc. (CAPP; ITP, Univ. of Zaragoza, Spain; PIMS, Canada, etc.).

Effectiveness of the enrichment programs and challenges in running them

Research on these programs has shown that they result in a more positive attitude towards psychiatry (ATP-30), better knowledge about psychiatry, greater skills acquisition, and better academic performance, including better performance compared to psychiatry residents getting enrolled through non-enrichment programs (Maryland). Also, a greater interest in psychiatry as a career (Canada), higher recruitment in psychiatry (CIPM, PEEP), promoting a research mindset (ITP), and an appreciation for the relevance of psychiatry in other medical disciplines (PEEP) were found. Therefore, inducing such enrichment programs at various stages, and of varying intensity, in medical education can enhance psychiatry training of medical students, including utilization of learned skills in medicine in general, thereby contributing to implementing CBME more effectively.

However, such programs bring with them certain implementational challenges. First and foremost is their replicability in different settings, particularly in LMICs, which have limited psychiatric professionals to cater to the individualized needs of such attendees. Secondly, for the success of such programs, the participation of motivated teachers and administrative support is required; on the contrary, in most universities (particularly in LMICs), teachers are already overburdened to be motivated enough to shoulder extra responsibilities, particularly when their efforts are not adequately incentivized. Thirdly, long-term efficacy data on the positive outcome of such programs on psychiatry recruitment and sustenance of the students’ interest in psychiatry is still limited. Thus, the willingness of academic institutions to endorse such programs in low-resource settings may be lesser. Lastly, it needs to be deciphered if the better performance of such programs is solely attributable to the quality and intensity of training or other factors (e.g., extra attention from the program coordinators, other incentives received) play an equal role.

Medical education across the globe during COVID-19 challenges and opportunities

The COVID-19 pandemic has greatly affected medical education across the globe, including the paradigm of CBME. The outbreak has also affected students’ psychiatry training by disrupting their classes, clinical postings, or assessments.[8,15] Institutes across the world, including India, have come out with innovative T-L models (online classes, SG discussions, case simulations, ensuring availability of the resource materials, modified format of assessment) to circumvent these problems. However, their scope and implementation have been non-uniform.[13,15] The latter is attributed to a lack of teaching workforce, difficulty adjusting to the virtual model of T-L and assessment, and non-exposure to the patients, thereby affecting the acquisition of clinical skills, maintaining a teacher–student relationship, and formation of students’ professional identity.[15]

Simultaneously, the pandemic has brought many opportunities, especially those conducive to the realization of CBME: flexibility in training with greater emphasis on skill-based or learning-based curriculum vis-à-vis time-based curriculum, learning crossing boundaries through accessing online materials at one’s convenience, promoting peer-learning, self-directed learning (a vital component of CBME), innovation in training (case simulation, novel assessment methods) and assessment (developing EPAs), acquisition of digital skills to access information and critically synthesizing them, and greater opportunity to connect with teachers.[8,46]

DISCUSSION

Undergraduate medical education has undergone a substantial transformation over the years, with an inclination towards CBME. Many countries, particularly HICs, have adopted it in their curriculum and innovated to make it more student-friendly, particularly through various enrichment activities. LMICs have also embraced it to various extents; CMBE has been in different stages of implementation across them. However, this brings challenges at the administrative and teacher–students level, yet it opened opportunities to make medical education more relevant and outcome-oriented. Moreover, the COVID-19 pandemic has shown the CBME framework to be more relevant and necessary than ever before. This paper has highlighted the global pattern of CBME, its implications for medical education in India and other LMICs, and recommended certain future directions.

Implications for psychiatry training under the CBME in India: Challenges and way forward

The enrichment activities (short courses, electives, etc.), which have proved effective in reducing stigma related to mental illness, busting the myths associated with psychiatry, and improving students’ skills, can be replicated in the Indian setting to train students in an opt-in manner. This exposure would help in recruiting students in psychiatry and inculcating the skills of providing holistic care that is culture- and gender-sensitive. Furthermore, the experience and skills learned through such programs would help them promote peer-based learning, build student-leaders who can lead SGs in teaching, and promote self-directed learning, thereby making them better placed to serve society. However, there are the following challenges in implementing CBME and enrichment activities in psychiatry in India [Table 3]:

Table 3.

Challenges in implementing CMBE in psychiatry and the way forward

Challenges	Way forward
Administrative blocks	Upgrading medical education department of the medical schools.
-Lack of trained professionals or medical educators	Training, peer-support, and mentoring teachers to effectively implement CBME.
	Effective utilization of human resources.
-Resource constraints	Training and supporting teachers in effective utilization of time and resources for UG training.
-Overburdened teachers or consultants	Collaborating with organizations like IToP (Indian teachers of Psychiatry, departments of education and technology, etc.) to enhance the skills of teachers in training.
Attitudinal block or old teaching culture	Orienting college administrators, HODs other disciplines and teachers about the significance of psychiatry training in implementing CBME.
	Supporting them in acquiring teaching skills.
	Priming students about the scope of psychiatry.
Lack of trained psychiatry teachers (High student teacher’s ratio)	Forward feeding of the student’s information concerning their level of competencies from UG to PG and working on the weak areas.
	Effective utilization of human resources (teachers, psychiatry residents, tutors, student-leaders, etc.) in planning and implementing CBME.
	Utilizing national knowledge network and digital India platform to integrate expertise across institutions.
Lack of robust assessment methods	Developing locally relevant evidence-based assessment tools.
	Collaborating with the education and technology departments, etc.
	Feedback from students on the assessment methods and required changes.
	Developing entrustable professional activities (EPAs) to assess skills.
	Greater emphasis on work-based assessment, mid-term rotation assessment.
	Utilizing novel and multifaceted assessment models.
The negative attitude of medical students towards psychiatry	Early exposure to psychiatry or behavioral sciences.
	Incorporating psychiatry in the foundation course.
	Short enrichment or orientation program.
	Promoting integrative teaching: integrating psychiatry with other disciplines of medicine as well as training psychiatry in the non-psychiatry block.
	Multidisciplinary teaching: taking on boards consultants of other departments.
Lack of innovation	Utilizing digital technology in training and assessment.
	Utilizing low and high touch activities and allocating resources accordingly.
	Blended learning approach to bridge the gap of high student/teacher ratio.
	Training of teachers (workshops, seminars, etc.) in novel methods of teaching and assessment.
Financial and human resource implications for implementing CBME	Collaborating with the funding agencies and education department.
	Infusing funds in upgrading the medical education deparment of medical colleges.
	Funding enrichment programs or activities.
	Encouraging research on developing or adapting existing training modules that are locally relevant.
Lack of leadership from psychiatric teachers	Psychiatric teachers must take a leadership role in strengthening psychiatry training and its integration.
	Highlighting the positive impact of competencies learned during psychiatry training in other disciplines of medicine.
	Advocating for psychiatry as a major subject or a subject which is to be mandatorily passed.
	Taking leadership in organizing, conducting, and collaborating with others for various enrichment activities.

CBME: Competency-based medical education, HODs: Heads of departments, PG: Postgraduation, UG: Undergraduate, IToP: Indian Teachers of Psychiatry

Administrative blocks: It incluces the lack of trained professionals/educators to take up these tasks at the institutional level, resource constraints, multiple responsibilities that teachers (or consultant psychiatrists) must shoulder in medical schools, etc. The potential solution is to develop and strengthen the medical education wing of each medical institution in the country.[47] Peer support, mentorship programs for colleagues, workshops, etc., are other functional strategies.[8] Some laudable steps in this direction have been taken by the medical council of India (MCI) and Indian Teachers of Psychiatry (IToP)[48] which have initiated a teachers’ training program in the arts of teaching and evaluation.

Attitudinal block among the teachers: Due to inner inertia and lack of orientation, teachers tend to resort to the traditional model of teaching and evaluation of the students.[47] Hence, teachers (also students) must be adequately primed in CBME, support them in delivering the principles of CBME, and recognize their efforts, including incentivizing them (considering it an achievement worth highlighting in one’s curriculum vitae).

Disproportionate student teachers’ ratio: Due to it, conducting SG discussions, assigning short research projects, personalized mentorship, etc., becomes problematic in the Indian setting, particularly when so many medical colleges are being set up across the country. Therefore, utilizing psychiatry residents, collaborating with other disciplines (interdisciplinary training) and organizations (multi-professional training), and identifying motivated student-leaders (including attendees of enrichment activities) in providing skilled-based training could be important strategies. Furthermore, utilizing platforms like National Knowledge Network and Digital India[49,50] to integrate psychiatry teaching expertise across institutions can be a substantially innovative step in correcting the mismatch in student/teacher ratio and disparity in psychiatry training.

Assessment methods: CBME, at its core, has an essential aspect of formative and summative assessment. However, again, following the traditional teaching model and lack of availability of the entrustable competencies and validated tools to measure them, this part often remains neglected, resulting in sub-optimum evaluation, thus limiting students’ opportunities to learn the required skills. Identifying EPAs to assess the skills, mid-term rotation assessment, utilizing novel and multifaceted evaluation models (OSCEs, debates, case-based learnings, tackling treatment non-adherence, psychoeducation to patients and their family members about the disease, etc.), digital simulation techniques for T-L are potential strategies in this regard.

Addressing students’ stigma towards psychiatry: Students’ resistance to psychiatry training and the stigma associated with the subject can also be addressed by enriching the foundation course by incorporating essential aspects of the behavioral sciences and making it mandatory for the students.[29,51,52] Psychiatry teachers must play a significant role in sensitizing the students and invoking interest in mental health and related issues in medical courses. Multidisciplinary teaching, including delivering psychiatry training in the non-psychiatry block of the hospital, is another effective way to make psychiatry more relevant and decrease its stigma.[2,21]

Innovative methods of psychiatry training: Itincludes utilizing novel methods of psychiatry teaching based on low and high touch approaches. For instance, low touch activities that require less supervision (e.g., signs and symptoms in psychiatry, theory, psychopathology, etc.) can be utilized during the foundation period of the students and achieved through interactive online activities. While high touch approaches can be considered for the competency-based activities (interviewing techniques, psychoeducation, delivering psychotherapy) where SG teaching or activities can be supervised by a tutor or psychiatry resident, or senior faculty member in the later part of the curriculum.[3] Incorporating a blended learning approach (aligned combination of the online and face-to-face T-L method) in psychiatry teaching can be a helpful step; it would also overcome the shortcomings of the traditional T-L approach.[53,54] Similarly, immersive psychiatric training through digital simulation methods can strengthen the training, such as learning interview techniques and communication competencies in a safe, controlled milieu.[12] Online courses provide just-in-time learning that students can refer to as and when required to master a particular skill, which can also be customized (interactive or didactic).[3]

Future direction

Considering the opportunities and challenges in implementing CBME worldwide, particularly in LMICs, continuous innovations, evaluation, and course corrections are warranted. For instance, the curriculum should be developed or modified by seeking inputs from the academic institutes, program coordinators, accreditation bodies, etc. The course can be effectively delivered, taking the support of online course developers and education technologists. Similarly, assessment techniques can be strengthened through digital simulation techniques, online interactive quizzes, case-based discussions, OSCEs, and breakout rooms (Zoom or another platform) for SG assessment (individualized or team-wise).[3,8]

Apart from the implementation, the CBME curriculum needs to be assessed periodically for its effectiveness and feasibility. Such evaluation can be carried out, for instance, by utilizing context (identifying unmet needs, unused opportunities, and underlying problems that prevent meeting those needs or using the opportunities pertaining to CMBE), input (perceived definition of CBME by stakeholders, determining competencies, and meaning of those competencies in medical education and achieving excellency), process (monitoring project operations such as content, teaching–learning experience, assessment methods, etc.) and product (CIPP) evaluation (contributions of CBME to students’ academic or vocational developments) model.[55,56] It should be followed by necessary course corrections, including making it relevant for the country’s medical education and catering to the needs of society.

CONCLUSION

Psychiatry training of medical students is a vital component under CBME, and also in the realization of the goals of the CBME framework under NMC 2019 (India). The medical educationist in general, and psychiatry teachers, need to adapt themselves to provide competency-based teaching to the students so that the latter can contribute to the needs of society and develop as a better professional. Making structural changes in the curriculum, orienting teachers and students about CBME, mentoring teachers, adapting novel T-L methods, utilizing enrichment activities, collaborating with educational institutions and technology providers, periodically evaluating the implementation of CBME, and making appropriate course corrections are essential. Additionally, more implementational research and designing locally relevant curricula and resource material are warranted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY FILE 1: SEARCH STRATEGIES

Pubmed search strategy: (((((((((“medical education”[Title]) OR “medical undergraduate”[Title]) OR “medical curriculum”[Title])) OR “undergraduate”[Title]) OR “medical students”[Title]) OR “competency based medical education”[Title]) OR “competency based medical curriculum”[Title])) AND (((“psychiatry”[MeSH Terms]) OR “mental health”[MeSH Terms]) OR “behavioral sciences”[MeSH Terms]): yielded 188 records.

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allintitle: psychiatry training teaching medical OR students OR education OR curriculum OR competency: yielded 24 records.