Abstract
Introduction: Psychiatric disorders are hard to detect in a primary care setting. The vocational training for general practitioners (GPs) of the University of Maastricht, the Netherlands, intends to create a new comprehensive programme on diagnosing psychiatric disorders.
Aim: We consulted the literature to obtain an answer to the question: is evidence available for the effectiviness of specific educational methods to teach GP trainees psychiatric diagnostic skills?
Methodology: We searched in four databases for studies on a variety of search terms (39) referring to primary care, psychiatry, diagnosis, education and quality. As selection criterium for outcome measure we took change in diagnostic competence.
Results: From a number of 769 articles 27 methodologically sound studies remained. This article presents several of their research characteristics. No conclusive evidence has been found for the effectivity of an isolated educational method. The combination of methods seems promising. However, no specific mix of methods is a guarantee for success.
Conclusions: We made some recommendations for training psychiatric diagnostic competency. The literature endorses our own idea that education in this field should include reflection on attitude and barriers.
Introduction
Psychiatric disorders are widespread among the population at large and highly prevalent in primary care patients. Based on several large research projects conducted among the general population in the Netherlands, prevalence estimates range from 17 to 25 percent (Vollebergh et al. Citation2003). These numbers are in line with findings of research conducted internationally (Mason & Wilkinson Citation1996; Saraceno Citation2002). In guidelines and general standards for dealing with psychiatric disorders, providing the right diagnosis is seen as a core task for general practitioners (GPs) (Wiersma & Goudswaard Citation2006; CBO Citation2007). Diagnostic competency, therefore, forms the basis for primary care interventions for psychiatric disorders and, consequently, is essential for GPs and future GPs to acquire.
The literature shows, however, that there is a marked underdiagnosis of psychiatric illnesses by GPs (Lieberman Citation1996) and there appears to be a large gap between the demands made on GPs and their actual clinical practice. One way to bridge this gap is that GPs should become more competent in psychiatric diagnosis by education of GPs and trainee GPs. Therefore, it is crucial to obtain an answer on our research question: which educational methods are most effective in teaching these skills to both trainee GPs and established practitioners?
A first quick scan of the literature produced two thorough reviews of education in psychiatry. Kroenke et al. (Citation2000) analysed 48 studies in order to look for efficient methods of teaching diagnosis and treatment of psychiatric illnesses. They concluded that education did lead to an increase in diagnostic skills. They were however unable to link these improvements to clearly delineated educational methods. Moreover, this review did not specifically target GPs. Hodges et al. (Citation2001), on the basis of their study of over 400 publications, provide recommendations for objectives, methods and evaluation in teaching psychiatry in general, but fail to put forward educational suggestions for changing GPs’ actual behaviour in the clinic. They do, however, recommend taking GPs’ attitudes into account in providing education in psychiatry.
Neither of them answered our research question: which educational methods could be most effectively employed to teach trainee GPs psychiatric diagnostic skills? Furthermore, as it is now 7 years since these reviews were published, we wondered about current developments in the field.
Methodology
Research framework
To discover which educational methods are effective in teaching psychiatric diagnostics to GPs and GP trainees, we included studies that had change of behaviour as outcome and excluded studies whose outcome was change in knowledge and skills. Our research focused on studies in Medline, EMBASE, the Cochrane database, Psychlit and a number of Dutch journals such as Huisarts en Wetenschap (General Practitioner and Science) and Tijdschrift voor Medisch Onderwijs (Journal of Medical Education). We searched for studies in Englisch, French, German and Dutch. We covered the period 1995–2008 and conducted keyword searches using the MeSH or Thesaurus search terms: ‘Family Practice’, ‘Physicians, Family’, ‘Ambulatory Care’, ‘Primary Health Care’, ‘General-Practitioners’, ‘Family-Medicine’, ‘Family-Physicians’, ‘Outpatient-Treatment’, ‘Residency’, ‘Medical-Residency’, ‘Education’, ‘Learning’, ‘Teaching’, ‘Psychiatric-Training’, ‘Competency-Based Education’, ‘Education, Medical, Continuing’, ‘Professional Competence’, ‘Clinical Competence’, ‘Competence’, ‘Psychiatry’, ‘Mental Disorders’, ‘Depression’, ‘Anxiety Disorders’, ‘Psychotic Disorders’, ‘Substance Use Disorders’, ‘Somatoform Disorders’, ‘Diagnosis’, ‘Health Care Quality, Access, and Evaluation’, ‘Quality Assurance, Health Care’, ‘Quality of Health Care’, ‘Quality Assessment’, ‘Competency Assessment’ and ‘Quality Improvement’. Text word searches were done using the term ‘general practice’.
The snowball method was used to scan the reference sections of relevant articles for additional publications.
Inclusion and exclusion criteria
We have made the choice not to use the EPOC (Citation2002) inclusion criteria for this review, as we wanted to find a wide range of ideas. Moreover, we found it important to use the qualitative opinions of the recipients of the educational interventions.
The studies selected were randomised controlled trials (RCTs), controlled before and after (CBA) studies or interrupted time series (ITS). Studies that compared two or more teaching interventions and studies that measured the efficacy of an intervention through self-assessment were also inclueded. Studies that only measured the effectiveness of teaching interventions at the knowledge level, as well as studies relating to others than primary care physicians were excluded. Finally, studies of the treatment of psychiatric disorders were not included.
Data collection and analysis
The studies identified by the search were judged by two reviewers independently, stepwise on title, abstract and full article. In case of disagreement, a third reviewer determined the final choice.
Results
Totally 699 articles were identified by the literature search. Finally, 27 articles were included. depicts the selection process. In the 27 included articles are summarized.
Figure 1. Search, screening and selection of studies.
Table 1. Details of included articles
The 27 selected articles can be divided in 8 RCTs &, 6 CBA and 13 ITS. In the studies, reference is made to different educational methods that have been used as interventions. In all cases but two a combination of methods is used. Even study 25 employed a combination of methods because it included pre-study measuring which can be regarded as an educational intervention in its own right. In most cases, the educational methods are mentioned but not described. lists these educational methods used.
Table 2. Educational methods reported
In addition to using this wide variety of educational methods, different educators such as psychiatrists, nurses and fellow GPs were employed. Moreover, group size varies, ranging from small and large group instruction to teaching on an individual basis. The duration of the interventions varies greatly, from a number of hours to one whole year. A number of studies discuss a broad-based program over a longer period of time involving a large number of educational interventions. The number of physicians taking part in these studies ranges from 12 to 303. A minority of studies involves larger number of doctors. Three studies with quite remarkable results were conducted in non-western cultures. The entry level of qualification of GPs is described in the studies to be lower than in our region. The studies in western societies were mainly conducted among physicians who had already completed their primary care education. This may explain the difference in effects of education.
The results of the interventions were measured in various ways. Eight of the findings came about as a result of self-assessments in the form of specially formulated questionnaires for the study in question. Twelve studies measured behavioural changes among physicians, using standardized patient measurements, video recordings or scored diagnoses. Seven studies measured results by patient outcomes. The final column in the table shows short comments provided by the two reviewers. As a whole, these studies provide a fascinating and comprehensive view of a decisive part that has been attempted in this field so far. The studies are difficult to compare because of the great variation in educational methods employed, the variety of research methods and the different standards of measurement. By combining educational methods three out of eight RCTs find an improvement in competence in diagnosing psychiatric disorders. The CBA and ITS studies altogether show more positive results: 13 studies demonstrate an improvement; some of these studies are not very convincing in design, pursuance and results. No result can be explained by one intervention.
Discussion
During the study, we noticed that the problem of underdiagnosis of psychiatric disorders is recognized worldwide and that it is perceived to be a persistent problem. This broad acknowledgement encouraged us to continue our research. In this conscientious selection process we find a large number of articles, but a lot of them are excluded. All the articles, included and excluded, have contributed to our overall understanding and have reinforced our conviction that effective educational methods are still unknown is a problem, which deserves further attention.
The included articles produce no conclusive evidence for particular educational methods. Reflecting on these inconclusive findings we try to find an explanation for why they fail to live up to our expectations. This, in turn, leads to considerations not only pertaining to the development of a new curriculum but also to options for future research projects.
Our explanations
It is important to answer the question: why so little evidence is found in spite of the substantive research efforts? We feel that the skill to diagnose psychiatric disorders is so complex for GPs that there cannot be any correlation between one or more specific educational interventions and actual behaviour change. The phenomenon of the lack of efficacy of educational interventions may be caused by a complex set of factors, which are partly linked to GPs’ personal characteristics. Practical matters, as well as a variety of motives, insights, experiences and interpretations may all play a role in GPs’ behaviour and this may inhibit acquiring new skills. All these factors are still relatively unknown. Awareness of and insight into these factors can improve the effectiveness of educational interventions. In many of the studies the trainees’ attitude is regularly mentioned. As argued above, it seems useful to pay attention to attitude, which ties in with Hodges et al.'s (26) recommendations.
We also noticed that although physicians are regularly polled as to what skills they hope to acquire, there was no overview of preferred methods for acquiring these skills before interventions were applied. Especially where psychiatric diagnostics are concerned, it may be essential to know how GPs themselves feel they should learn these skills, i.e. which educational methods best suit their learning needs. It is worth asking their preferences as to how this material should be taught.
Learning a new skill is easier than changing already established behaviour. To change learned behaviour it first has to be unlearned. The majority of the studies included were conducted with established GPs, which may explain why the results were less substantive than with trainee GPs, as the former category already had patterns of behaviour that first needed to be unlearned.
None of the interventions included educational methods currently considered most appropriate to teaching complex skills, i.e. individually tailored education with a large degree of personal responsibility for self-directed learning. This means incorporating personal factors, which may influence the learning process. The lack of such a study may explain the lack of results.
Neither did any of the interventions included in our study show an integrated design for learning complex professional competences, with great attention being paid to integrating knowledge, skills and attitudes through working on learning tasks.
Lack of established improvement may be due to perceived good–practice by the GPs, who renounce labelling psychiatric symptoms. This may mean that all goals, standards and guidelines which induce the GP to provide a diagnosis first, do not fit in with what GPs themselves consider good practice. This impression is underlined by several studies (McCall et al. Citation2002; Saitz et al. Citation2003, Venrooij-Dassen et al. Citation2005) that note a great reluctance to psychiatric diagnoses. Are GPs right when they do not wish to ‘psychiatrise’ large portions of society? In other words, it remains to be seen if patients do indeed benefit if many more of them leave the clinic with a psychiatric diagnosis. This means, in practice, that it has to be absolutely clear to GPs that improved diagnostics means improved practice, and that their patients will ultimately benefit. Therefore, GPs have to be predisposed by very convincing arguments for change in behaviour.
Conclusions
Much has been done to train GPs in diagnosing psychiatric disorders, and educational methods to achieve this have been extensively discussed in the literature. Our findings provide no conclusive evidence for particular educational methods to teach this competency in spite of enormous efforts and great creativity on the part of a large number of educators and researchers from many different backgrounds. However, there is evidence that a combination of educational methods can improve the diagnostic competency of GPs.
We have not found any evidence for GP behaviour change that was consistent over a longer period of time.
On the basis of our study we would like to make some recommendations. However, as they are based on a barely perceptible trend and not grounded in convincing evidence they must, as yet, remain tentative. These recommendations are on line with the design of integrated practice for learning professional competences, which describes an approach for learning complex skills (Janssen-Noordman et al. Citation2006).
In order to provide effective diagnostic competency training, any intervention should include practice related combination of educational methods with case studies, role-play, feedback, video and discussion.
This combination of educational methods should take place in small teaching groups with systemic interactive approach. Besides, the program must be flexible and based on individual needs and prioritized topics (subjectives and objectives). Attention should be paid to the combination of knowledge, skills and especially to attitude. The education must be characterized by progress and development.
Confronting GPs with new guidelines and general standards with the complicated assignment of providing the right psychiatric diagnosis is not effective. A mosaic of educational methods, attuned to the needs of the group, however, seems not to miss its effects.
Summary
We aim to create a comprehensive program in the primary care curriculum to teach trainee GPs competence in psychiatric diagnostics. This study was meant to provide insight into what would be effective educational methods to achieve this. For this reason we have made a search on studies that had change of behaviour as an outcome. As a result we have included 27 studies after selection. Our findings so far provide no conclusive evidence for particular educational methods to teach this difficult skill. A combination of educational methods can be effective to learn psychiatric diagnostics. We tried to find an explanation for why they fail to live up to our expectations.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.
Additional information
Notes on contributors
Gerard H. H. Benthem
G. H. H. BENTHEM, General Practitioner, Department of Postgraduate General Practice Education, University of Maastricht.
Ruud R. Heg
R. R. HEG, General Practitioner, Department of Postgraduate General Practice Education, University of Maastricht.
Yvonne D. van Leeuwen
Y. D. VAN LEEUWEN, MD, PhD, General Practitioner, Department of Postgraduate General Practice Education, University of Maastricht.
Job F. M. Metsemakers
J. F. M. METSEMAKERS, Professor. MD, PhD, General Practitioner, Department of Postgraduate General Practice Education, University of Maastricht.
Related Research Data
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