Postgraduate training in psychiatry in India with focus on mumbai.

The present article traces the formation of the Indian Psychiatric Society and the progress of post-graduate training in psychiatry in India in general and Mumbai in particular. It covers the standard of psychiatric education, the goals and recommendations for improvisation of residency programmes, and the future of post-graduate psychiatric training.

Introduction: The Psychiatric Scene in India

Indian Psychiatric Society was founded in January 1947 (Sethi, 1978).[9] The Society appointed a Committee on Post-graduate Psychiatry Education in the same year (Indian Psychiatric Society, 1965[4]). The first M.D. Psychiatry course was started by Medical College at Patna and the first M.D. candidate was late Professor L.P. Varma, a Past President of the I.P.S. from 1947 to 1967. There were only six institutes all over India offering post-graduate M.D. degree and only 14 psychiatrists qualified as MDs. As on July 2010 there are 112 medical colleges and post-graduate institutes, which admit 266 MD degree students in Psychiatry each year (Kulhara, 1985[6]). In addition, 55 medical colleges have training for diploma courses for DPM. About 60 post-graduate appear for National Board Examination for DNB (Sharma, 2010[13]).

Various articles have been published in the Indian Journal of Psychiatry from time to time highlighting the advance of psychiatric education (Dale et al., 2007[2], Sharma, 1979[11], Sharma 1984[12]), survey of post-graduate training centres (Kulhara, 1884[5]), methods of assessments (Gopinath and Kaliaperumal, 1979[3]), need to train the trainers (Bhaskaran, 1990[1]), undergraduate training (Tharyan et al., 1992[14], Murthy and Khandelwal, 2007[8]; Trivedi and Dhyani, 2007[16]) and role of general hospitals in post-graduate training (Kulhara, 1985[6]). All this articles helped in the improvement in post-graduate training.

In the last 40 years, psychiatry has grown as a speciality, and there are a greater number of psychiatrists and greater awareness of psychiatric disorders. The speciality itself has become more specialised into different sections like Child and Adolescent Psychiatry, Biological Psychiatry, Community Psychiatry, Forensic Psychiatry, Military Psychiatry, Rehabilitation Psychiatry and the latest addition, Geriatric Psychiatry (Sharma, 1976[10], Sharma, 2010[13]).

The Psychiatric Scene in Mumbai

Mumbai has four medical colleges. Mumbai Municipal Corporation administers three and the Maharashtra Government governs one. Each of them has a Psychiatry department with inpatient and outpatient facilities and trained qualified teachers. The Mumbai University recognises each department and hence the teachers are automatically recognised as examiners for MD and DPM examinations; they are also on the approved list of examiners for other universities throughout India as external examiners.

KEM hospital has two psychiatric units and each unit has three teachers and can have two MD and two DPM candidates. Sion Hospital has one unit and can have one MD and one DPM candidate. Nair Hospital has two units and can have two MD and two DPM candidates, and J. J. Hospital has one unit and can have one MD and one DPM candidate.

Mumbai University sends the list of lectures for each stream for each term and accordingly the respective teachers delivers lectures. These lectures are mostly in the afternoons after outpatient department hours (actually the residents are on their feet from 8 a.m. and, therefore, get tired, and yet have to attend these lectures); and the venue is the department of the respective teacher who takes the lecture (and fatigue and distance to reach the venue puts one off). Departments also have qualified Clinical Psychologists and trained Psychiatric Social Workers. However, their role in teaching is minimum or none at all.

Standard of Psychiatric Education

Medical Council of India (MCI) guides the objectives and standard of psychiatric education. It formulates the rules and curriculum of studies and also charts out the minimum requirements for teaching centres, quality of teachers and examinations conducted by universities. The recommendations of the MCI are mandatory and have to be fulfilled before an institution or college is recognised as a post-graduate department (MCI).[7] The following are the essentials:

(a) The teaching staff must be adequate and qualified. (b) The student to teacher ratio must be satisfactory, normally one post-graduate student (MD) per teacher per year — from 2010 this ratio has been changed to two MDs for one teacher. (c) The ratio of student to number of patients he handles must be satisfactory. (d) Each post-graduate teacher must have at least 40 in-patients with out-patient, follow-up and adequate laboratory facilities and a library for research in the Unit.

The selection of MD students must be strictly on merit, and in some institutions credit must be given to their work in rural areas.

The duration of a post-graduate degree course must be for a minimum of 3 years and for the diplomas 2 years, after 1-year of compulsory rotating internship in a recognised medical institution. This period of 3 years training has to be full-time, and every post-graduate student must be either a full-time resident or a full-time scholar.

With regard to the content and method of training, the main purpose must be to expose the student, by graded residency posts, to all branches of clinical psychiatry and also neurology. The student must participate in the care and management of patients, and must be given increasing responsibility as his experience develops. By the time he is in his last year of training, he must be able to diagnose and initiate treatment independently. During training, he has to become conversant with allied subjects such as neuroanatomy, neurophysiology, neurobiochemistry, including electroencephalography, neuroradiology, psychology, and social work.

Organization of the teaching programme is a complex task for anyone given this kind of responsibility. It is easy to preach ideals but difficult to practice, and at present, our leaders face two formidable tasks:

First, to train and provide service to the mental healthcare of 1.2 billion population;

Second, to maintain high standards in the scientific field in order to ensure a high quality of teaching and research activity.

Goals of Psychiatric Education

To produce competent and knowledgeable specialists.

To have competent medical teachers.

To have trained psychiatrists to carry out research in psychiatry.

To achieve these goals curriculum for psychiatry should aim to equip the trainee with relevant theoretical knowledge and develop practical and clinical skills including communication skills and training in research methodology. The following is recommended:

Theory should include Basic Sciences, Neuroanatomy, Neurophysiology, Genetics, Neurochemistry, Neuroimaging, Psychopharmacology, Psychology, Social Sciences, Statistics and Epidemiology.

Clinical assessment of all psychiatric disorders.

Aetiology and pathogenesis of psychiatric disorders.

Therapeutic approach as to appropriate pharmacological drug, use of psychotherapy and family therapy.

Assessment of prognosis and education of caregiver.

Rehabilitation plan and follow-up schedule.

Recommendations for Psychiatric Residency Programme: Total Duration 3 Years

3 months in Neurology to refresh knowledge of Clinical Neurology and to provide an insight into Neuropsychiatic disorders.

2 years in General Psychiatry to provide good exposure to Adult Psychiatry, Geriatric Psychiatry, and Child and Adolescent Psychiatry. It will also give a good exposure to specialty sections and help the trainee decide if he wants to specialise in any of them.

6 months in Consultation and Liaison Psychiatry to understand interaction between medical and psychiatric disorders. Also to appreciate the psychological, cultural and social aspects of medical illnesses and its effects on patient and family.

3 months in Community-based Psychiatry. This will be a different experience compared to hospital-based psychiatry and will develop leadership quality for working as a team.

Flowchart of the paper

Conclusions [Figure 1: Flowchart of the Paper]

Psychiatry as a speciality, as also post-graduate training in psychiatry, has come a long way. However, post-graduate training programmes are not adequate and show wide variations in spite of MCI guidelines and regulations. Such variations are not only within the country but also from country to country. WHO, along with WPA, has published, “Atlas: Psychiatric Education and training across the world” (WHO Atlas, 2005[17]). The aim of post-graduate training is to train the student so that he becomes a competent and knowledgeable specialist and a teacher who can cater to the needs of the student community and discharge his or her professional obligations ethically. He should also have some foundation in the principles of research methodology. Retrospective introspection and improvisation are needed all the time (Thirunavukarasu and Thirunavukarasu, 2009[15]). Hence, the training programme needs to be constantly evaluated and improved in view of constant change in social, economical and technological areas.

Take Home Message

Post-graduate training programmes in psychiatry are not adequate and show wide variations in spite of MCI guidelines and regulations.

They need to be constantly evaluated and improved in view of constant change in social, economical and technological areas.

Questions that this Paper Raises

Why should we not have Multiple Choice Questions for P.G. Examinations instead of essay type questions?

Why not have one examination body for the whole country or, to start with, for the whole state?

How does training differ from state to state, its comparison and the effects of local language in the assessment of Mental Status Examination; and if any validation of the same has been done?

About the Author

R. R. Patel MD is a consultant psychiatrist in private practice. He was an Honorary Psychiatrist and Professor of Psychiatry at B.Y.L. Nair Charitable Hospital and T. N. Medical College from 1976 to 2004. Currently he is a visiting Psychiatrist at Bhatia Hospital, Children's Aid Society, and Umarkhadi Observation Home, Mumbai. He was postgraduate teacher for M.D. and D.P.M. courses and an examiner for M.D. and D.P.M. examination at Mumbai University, Gujarat University and Kolhapur University.

He was President of Bombay Psychiatric Society 1987-88, Assistant General Secretary, Indian Psychiatric Society 1988-90 and Chairman, Awards Committee, I.P.S. West Zone 2000-2003.

He has a number of publications to his credit and has presented a number of scientific papers at Zonal and National Psychiatric Conferences. He was awarded the prestigious Marfatia Award of the Indian Psychiatric Society in the year 2000.