Case vignette-based evaluation of psychiatric blended training program of primary care doctors.

INTRODUCTION: The need to integrate psychiatry in primary care is increasingly recognized as the favorable strategy worldwide. The contribution of primary care doctors (PCDs) is extremely important toward it. However, majority PCDs find it difficult to diagnose and treat common psychiatric disorders. Many training programs developed for PCDs, with different methods employed for posttraining evaluation. One of such program is blended psychiatric training program developed at our center. AIM: Case vignette-based outcome evaluation of on-site section of blended psychiatric training of PCDs at the end of 2 weeks.
MATERIALS AND METHODS: Two qualified psychiatrists designed the ten case vignettes after pilot use. Data were collected at baseline and at the end of 2 weeks on-site-training program. Major psychiatric diagnoses and treatments were covered. The responses to each vignette were evaluated with maximum marks 10 (5 each for diagnosis and treatment).
RESULTS: The mean age of the 21 participants was 43.1 ± 7.3 years. The posttraining score (83.42 ± 10.38) was significant higher than the baseline score (42.4 ± 23.10).
CONCLUSION: Blended program for training of PCDs in psychiatric disorders significantly improves their diagnostic and treatment capabilities.

INTRODUCTION

The fact that primary care doctors (PCDs) come across a large body of patients presenting with psychiatric disorders has been identified for a long time.[1] As a matter of fact, epidemiological studies done as far back as 1970s identified that up to half of total psychiatric treatment was provided by the PCDs.[2] These findings are echoed by even the recent studies, for example, the prevalence of depressive disorders was reported to be much higher in primary care attendees than in general populations[3] and on many occasions, the PCDs were the only doctors clients ever consult.[14] This identification by PCDs in psychiatry, however, has always been accompanied by the fact that the PCDs have been found to be lacking in effectively managing the needs and expectations of those with psychiatric morbidities.[156789] This may be attributable to a number of reasons such as limited time, low confidence of clinician, reluctance on part of the client to discuss symptoms, misdiagnosing somatic symptoms of illnesses as physical ailments or pressure of multiple roles expected out of a PCD, lack of proper training in psychiatry, unaware about asking right questions to elicit symptoms.[1011]

This has resulted in a large of group of authors and policymakers to focus attention on training of the PCDs in psychiatry and attempts at systematically studying the gains made. Written postcourse tests administered to PCDs have been found to be a valid instrument of evaluation and have shown increased capabilities in diagnosing and managing psychiatric ailments.[11213] There is, however, a large nonuniform body of training programs all over the world, making the task of identifying the most beneficial ones arduous.[14] Furthermore, most of these attempts have been made in developed countries while a large treatment gap exists in developing countries. For example, in India, against a weighted percentage prevalence of 10.6% for current psychiatric illness, a treatment gap between 70% and 92% across multiple disorders was identified.[15] The authors come across few publications[1617] for the region where effect of any training program for the PCDs on their ability to diagnose and manage common psychiatric conditions was evaluated.

Aim of this paper is to evaluate PCDs in psychiatry using case vignette method in pre- and post-design for the “2 weeks” “on-site” training phase.

MATERIALS AND METHODS

The current study was done on 23 PCDs from an Indian State who were trained at a Tertiary care Neuropsychiatric Center in South India under the District Mental Health Program of India. All PCDs are working in government sector after their undergraduate medical education (MBBS). Ethical Committee of institute approved this study.

Evaluation of PCDs was done using a pre- and post-design method using case vignettes, after 2-weeks on-site training section of a proposed 1-year long NIMHANS Extension for Community Healthcare Outcomes (ECHO) training, i.e., a Hub and Spokes model of periodic tele-mentoring.[18] As a part of NIMHANS ECHO, every fortnight the PCD (spokes) would present anonymized cases of patients from their own practice for management guidance from the NIMHANS HUB specialists and other PCPs followed by brief lecture on a disease-related topic using multipoint video conferencing technology.[18] The typical day of on-site training program consisted of 2 hs of didactic session on a topic, followed by a 2-h visit to the outpatient department and later, interview of a suitable psychiatric patient relevant to the day's topic with discussion for up-to an hour. The physicians were also required to take two online tests during the duration of the training.

Case vignettes

Ten case vignettes and their answer keys pertaining to common psychiatric presentations in primary care settings, were prepared by a team of public mental health professionals and psychiatrists. The vignettes included clinical scenarios involving depression, mania, psychosis, generalized anxiety disorder, panic disorder, dissociative disorder, somatization disorder, epilepsy, alcohol harmful use, and alcohol dependence syndrome. Each vignette was worth 10 marks, five each for diagnosis and management (a total score of 100). Case-vignettes are available on request from corresponding author.

The PCDs were administered the vignettes before the commencement and after the completion of the onsite training program. All entries were then scored by a single rater using the answer key. The participation in this study was optional for the PCPs and informed consent was taken.

RESULTS

Out of the 23 participants, one was dropped as he was a qualified psychiatrist currently employed as a PCD and another withdrew consent to be the part of the study. The mean age of the participants was 43.1 ± 7.3 years. On performing paired sample t-test, the posttraining score (83.42 ± 10.38) was significant higher than the baseline score (42.4 ± 23.10) (t = −9.1, df = 20, P < 0.001).

The improvement was significant across all the vignettes [Figure 1]. The effects of training were especially pronounced in areas of diagnosing and managing mania, dissociation, and somatization disorders. Abilities in diagnosing and managing depression and epilepsy, although showed significant improvement, were found to have higher scores even at the initiation of year-long training.

Figure 1

Pre- and post-training mean scores across the case vignettes

Authors also mapped the pre- and post-training scores of all the individuals [Figure 2] and found that all the individuals showed improvement and while the abilities were widely separated at the beginning of the training, they seemed to converge toward a more uniform level.

Figure 2

Pre- and post-scores of individual participants

DISCUSSION

It is widely understood that an evaluation system is indispensable for any training system. This becomes even more salient when the area includes public health and large-scale implementation. There can be different ways, for example, multiple choice questions (MCQs), but these have limitations, a major one of which is the lack of information on clinical skills.[1619] Case vignettes have been shown to be a valid and good way of assessing the clinical skills of PCDs following training modules.[1617]

As discussed earlier, the multitude of training programs make it difficult for identifying the most effective strategies, yet through review of studies over 50 years, three major determinants have been identified.[20] These include the duration of the training module, the extent of active participation and degree of integration of new knowledge in the trainees' clinical practice.

The most common type of program has been short conferences held at a location away from the PCDs area of practice.[2122] These, however, have the issues of short duration and over indulgence in didactic style of training.[20] Researchers in other medical disciplines have established that optimum value from teaching programs can be reaped if continuing teacher-learner relationships are maintained as a part of longitudinal follow through programs.[2324] The psychiatric blended training program at our institute comprised of a longer onsite program (2 weeks) with 11 months of online continuing education, we also used additional teaching modalities apart from didactics which may have resulted in higher posttest scores in our sample.

Similarly, it has been demonstrated that a higher degree of involvement in the teaching process is necessary for changes in abilities of physicians in psychiatry.[23] Longer, interactive programs with active participation of trainees and case-based learning that allow opportunities to practice the skills learned, are conducive to sustained practice at primary level.[242526] During the training program at our center, ample opportunities for the trainees to get involved were made available. These included daily outpatient visits and interviews of patients. The end of the day also had an interactive session providing all the trainees an opportunity to interact with trainers, provide feedback and question further. Each day also started with a recap of the previous day provided by the trainees using a “teach back” approach.

The issue of clinical relevance arises as in a large majority (and even in our case), the training happens at a location far removed from the physicians usual practice area.[20] The maximum benefit has been observed when the trainees observe the care and improvement of patients in a primary care setup.[2728] The training program followed at our center had a second phase of online fortnightly continuing education and would present clinical cases and updates of psychiatric patients seen by them and this would be followed by a discussion by their peers and the experts at the center. The effects of the second phase have not been evaluated yet as it is continuing currently.

CONCLUSION

The 2 weeks on-site section of psychiatric blended program for training of PCDs in psychiatric disorders including didactics, case discussions, and outpatient-based training significantly improves their diagnostic and treatment capabilities with regards to common psychiatric disorders.

Limitations

The current study did not have any control group, and the postcourse evaluations were done immediately after completion of training thus recency effects may have contributed to higher scores. In addition, the PCDs' readiness and confidence to use these skills in real-world setting were not evaluated.

Future directions

It would be very important to be able to evaluate the PCDs after completion of the longitudinal phase of the training program and evaluate the capabilities in the real-world practice.

Financial support and sponsorship

This program is being funded by NHM and State Health Society Bihar.

Conflicts of interest

There are no conflicts of interest.