International Journal of Health & Allied Sciences

EDITORIAL
Year
: 2019  |  Volume : 8  |  Issue : 3  |  Page : 151--154

Role of psychiatry teachers training in national mental health services in India, reflection and roadways for future


M Kishor1, Mohan Isaac2, MV Ashok3,  
1 Department of Psychiatry, JSS Medical College, JSS Academy of Higher Education and Research (Deemed to be University), Mysore, Karnataka, India
2 Department of Psychiatry, The University of Western Australia, Crawley-Nedlands, Australia
3 Department of Psychiatry, St. John's Medical College, Bengaluru, Karnataka, India

Correspondence Address:
Dr. M Kishor
Department of Psychiatry, JSS Medical College, JSS Academy of Higher Education and Research (Deemed to be University), Mysore, Karnataka
India




How to cite this article:
Kishor M, Isaac M, Ashok M V. Role of psychiatry teachers training in national mental health services in India, reflection and roadways for future.Int J Health Allied Sci 2019;8:151-154


How to cite this URL:
Kishor M, Isaac M, Ashok M V. Role of psychiatry teachers training in national mental health services in India, reflection and roadways for future. Int J Health Allied Sci [serial online] 2019 [cited 2019 Oct 21 ];8:151-154
Available from: http://www.ijhas.in/text.asp?2019/8/3/151/263946


Full Text



India is the world's second largest country by population with more than 1.25 billion people. It is a country with high rates of mental health issues, including suicide.[1] National Mental Health Policy of 1982 laid a foundation for community-based mental health services in India.[2] Most of the population resides in rural areas, and thus, more often for all healthcare need, they invariably seek government healthcare services such as primary health care center (PHC) which is usually managed by one or two MBBS doctors. Hence, the key center for majority of mental healthcare services in India is actually a PHC and the key service provider is an MBBS doctor.[3],[4] It is a well-recognized fact from the WHO World Mental Health Atlas 2014 Report that trained mental health specialist in India is sparse, with just over 700 specialists trained every year, and hence, the best hope for any kind of mental health service intervention is in the training of MBBS doctor who is reasonably trained in psychiatry. In 70 years of independence, India has progressed much currently; 529 medical colleges are training more than 70,000 doctors/year.[5] Paradoxically, psychiatry training is not a mandatory part of evaluation either in theory or clinical examination in any phase of MBBS training in India!! and the Medical Council of India (MCI) which supervises medical education is not keen to include in MBBS examination anytime soon.[6] In such complex Indian scenario, the training of psychiatry teachers at undergraduate and postgraduate medical schools becomes paramount so that they do their best with the available opportunities and resources for sustenance and delivery of mental health services. It is clear from the above information from India context; national mental health services, psychiatry education, and psychiatry teachers training are interlinked.

The history of mental health services, that of psychiatry education, and the training of psychiatry teachers in India should have gone hand in hand, but the gaps have been wide all along. The modern medical education began in 1822 at a medical school in Calcutta, and in 1833, the then Governor General William Bentinck appointed a committee to examine medical education.[7] Thus, the system of “medical school” was abolished with starting of two medical colleges, one at Madras and other at Calcutta. A year before Indian independence, in 1946, there were 16 medical colleges; by 1949, there were 29 medical colleges; and by 1958, the number reached 50. It is interesting to note that before 1933, the General Medical Council of Britain was the authority for medical education, and the MCI was constituted only in 1934. It has a permanent committee on the postgraduate medical education since 1956.[8] It is interesting to note that the assessment of psychiatry training itself began in 1932 when Col. Berkeley Hill's survey of all medical institutes revealed no teaching on mental disorders at all; in some, just 20 lectures and clinical works ranged from 7 to 30 days.[9] Strangely 87 years later, till 2018, the MCI recommends psychiatry theory for 20 h and 2 weeks of clinical exposure in entire MBBS!! Even this training is optional for MBBS students who can make the required attendance through participation in other subjects. Any rightful cause needs an association of like-minded people; interestingly, it was again Col. Berkley Hill, the medical superintendent, European Hospital at Ranchi, who pioneered the formation of an association for mental health workers, and thus, the Indian Association for Mental Hygiene was formed in 1929.[10] However, it was Dr. Banarsi Das, the superintendent of Mental Hospital at Agra, who urged in 1936 to form an exclusive association of psychiatrist for this country, and he became the first secretary for Indian Division of Royal Medico-Psychological Association, later its chairman in 1941.[11] Indian Psychiatry Society (IPS) was formed in 1947 after Indian independence and the earlier association was dissolved. IPS since its inception has recognized the close association of mental services and the availability of trained mental health specialist, it has tried its best to address the teachers training in psychiatry which is so crucial for overall quality of trained specialist, and thus, immediately, IPS formed a committee on psychiatry postgraduate education. However, it was not until 1962, the first IPS subcommittee on undergraduate teaching of psychiatry was formed.[12] The committee surveyed 35 medical colleges that responded out of 56. Not surprisingly, one-third of the medical colleges had no teaching facilities in psychiatry. In remaining institutes, the psychiatry lecture was on average 20 and 7 h of clinic work in the entire MBBS course. Again as mentioned earlier, till 2018, the duration of undergraduate training in psychiatry as per the MCI is more or less same and MCI in the upcoming competency-based curriculum has proposed to enhance the duration of psychiatry with vertical and horizontal integrations with other subjects. However, it does not require single mandatory competency related to psychiatry as must for licensing examination for Indian medical graduate essentially, suggesting old wine in a new bottle![13] Undoubtedly, it reiterates the fact that after nearly seven decades of Indian independence, Indian doctors are still poorly trained to deliver mental health services. The proposed exit examinations (National Exit Test) for MBBS students is an golden opportunity to ensure that psychiatry is given its due, so the upcoming doctors are reasonably qualified to deliver mental health services.[14]

The efforts to train teachers in undergraduate psychiatry to an extent began in 1965 meet under auspices of the WHO and the Directorate General of Health Services, Government of India, at Central Institute of Psychiatry at Ranchi.[15] The meet highlighted the relevance of psychiatry and “what should be taught,” but it failed to give guidelines on how to implement them as it could neither influence the authority nor had plan of actions for training teachers. Interestingly, the meet had just one paper by Dr. C C Saha on Methodology of Psychiatry teaching, which mentioned teaching from 1st year to the end. It was again Dr. C C Saha who emphasized psychiatry postgraduate education in 1962 Presidential Address of IPS, which underscores that one has to be keen on both undergraduate and postgraduate psychiatry education in India for addressing mental health services.[16] It is of interest to note that for many years of independence, the medical colleges did not have psychiatry department at all, some psychiatrists were part of medicine department, and the first psychiatry department was started only in 1962 at All India Institute of Medical Sciences, Delhi.

Even though, in successive years, annual national medical education meets recognized the need to increase the quantum of psychiatry education, including Presidential Address at Annual National Conference of Indian Psychiatric Society (ANCIPS) and many studies were published in Indian Journal of Psychiatry on relevance of psychiatry training in undergraduate level but nothing much changed, psychiatry exposure for MBBS graduates remained inadequate.[17],[18],[19],[20],[21] Sadly, no emphasis was given to train psychiatry teachers who can effectively engage the undergraduates in allotted duration of training, even though the 1990 Editorial in Indian Journal of Psychiatry reminded the need.[22]

It is important at this juncture to look at the postgraduate psychiatry education and its link with undergraduate psychiatry, including the complex interaction of psychiatry education with National Mental Health Services. The first MD Psychiatry Course was started in Patna Medical College in 1941 and the first candidate was Dr. LPVerma, who later became the President of IPS.[23] From 1947 to 1967, only six institutes in India offered postgraduate in psychiatry and about 14 MD psychiatrists qualified from these centers, majority were Diploma in Psychological Medicine (DPM) holders, and over 100 Indian psychiatrists were trained abroad in the first two decades of independence.[24] All India Institute of Mental Health was started in 1955, renamed as National Institute of Mental Health and Neurosciences later and Central Institute of Psychiatry in 1962. Hence, majority institutes were run by government earlier, and in the last two decade, the majority of postgraduate institutions are private; currently, India has more than 200 institutions which offer postgraduate training in psychiatry (DPM, MD, and DNB); thus, 700 plus mental health specialists trained every year.[25] Even with this number, it is disproportionately low as compared to 1250 million population of India. The IPS formed the committee for guidelines for postgraduate training in India in 2002 which reported that there was a wide variation in content and delivery of training in India, but it did not mention anything on training of teachers. However, a decade later when around the world, there were significant changes in Psychiatry Training, in 2013 IPS formed a committee under Chairmanship Prof. Mohan Isaac, which also included the survey done, and the findings rightly emphasized that the MCI objective includes that postgraduate trainee should equip skills in educating. It also noted that an important aspect of effective training is effective trainer and the survey found much of the training for postgraduates in India is carried out by younger staffs who have not received any training in teaching methods. The guidelines clearly suggested that faculty should be sensitized about updating their teaching skills and should receive training in teaching methods. For the first time, it made a note of the fact that psychiatry postgraduate training cannot occur in vacuum; it can be effective only when placed in an appropriate training environment, which focuses on strong undergraduate grounding in psychiatry. In this IPS guideline, the objectives of postgraduate psychiatry training categorically mention “to develop the qualities of effective teacher.”[26] The sad part is the guideline missed the crucial part to mention any of them in competencies at the end of training!! And, for the last seven decades, very less efforts have been put into the training of postgraduate teachers who are more than 1000 in number for enhancing training of the psychiatry residents as teachers to equip them with essential skills for imparting training in undergraduate psychiatry teaching so that India reasonably meets the mental healthcare needs of population. This training of postgraduates as teachers is neglected even though nearly all of them after passing out, numbering about 3000 psychiatrists in India, are employed in teaching institutions, often in 529 medical colleges where focus is on undergraduate training. Thus, the current postgraduate training is directly linked with undertrained psychiatry teachers in medical colleges, the scenario gets complicated further without mandatory minimal psychiatry skill among MBBS graduate, and hence, these factors pose a major hurdle to address adequately National Mental Health Services in the Indian context.

Inadequate training of medical teachers is not something specific to psychiatry, it is true for large extent of medical education in India itself, and the training of teachers began only after the 1997 Medical Council of India (MCI) regulations.[27] The impact of such drawback is immense on public mental health services because of the added problem that patients prefer a physician, a nonpsychiatrist in India for their psychiatric conditions, who are in turn not trained. Training of teachers is essential for quality education and skill enhancement in medical colleges. In the last decade, the MCI has made 3-day faculty development program mandatory for medical college teachers, and thus, for the first time, some form of “how to teach” is being imparted. Psychiatry needs more such focused training for teachers.

Indian scenario is unique and the training of psychiatry teachers becomes crucial for National Mental Health Services. Some efforts in this direction, focusing on psychiatry teachers, are being consistently made at the Annual National Conference since 2013.[28],[29],[30],[31],[32] The emphasis is that nearly 3000 psychiatry teachers in Indian medical colleges should inculcate the art and science of teaching psychiatry amid other task and in this meager time provided under the current curriculum. Teachers have to innovate ways to engage the budding doctors in the areas of their interest at earliest and continuously work on “student-centric learning” modules including thinking “out-of-box” ideas such as exclusive monthly newsletter for undergraduates/free ebooks/awards for best undergraduates in psychiatry/awards for best undergraduate psychiatry teacher.[33],[34],[35],[36] Some of the IPS activities, such as quiz program, also attract undergraduate students toward psychiatry. Many such experiences need to be shared among all the psychiatry teachers so that unified efforts are made to kindle interest and learning across all MBBS students in nation on aspects of essential psychiatry. The exercise of engaging psychiatry teachers for above-said objectives and the need for such efforts have been presented and discussed over the past 5 years in various platforms at state/national/international meet (Karnataka Annual Conference of Indian Psychiatric Society (KANCIPS), ANCIPS, South Asian Association for Regional Cooperation Psychiatry).[28],[29],[30],[32],[35],[37],[38] Interestingly, in a yet to be published survey of Karnataka medical colleges revealed that there was felt need among the psychiatry teachers for formation of forum to share experiences. Also there was expressed need for joint efforts for adequate psychiatry training at all levels, that indeed benefits nation for providing improved mental health services.[39] Thus, a forum of Indian Teachers of Psychiatry (IToP) was formed in November 2016 at St. John's Medical College, Department of Medical Education, which is an MCI Regional Center, Bengaluru, under aegis of Indian Psychiatric Society, Karnataka Chapter, Department of Medical Education, which is also an MCI Regional Center, and Rajiv Gandhi University of Health Sciences which is one of the largest government health science universities in India with over 40 constituent medical colleges. The forum was inaugurated by the Director of National Institute of Mental Health and Neurosciences, Bengaluru. The IToP forum thus formed also conducted 1-day workshop on training teachers in undergraduate psychiatry, which was attended by representatives from more than 20 institutions and eight universities of Karnataka state, which has most number of medical colleges in India.[34],[37] An online forum was also created, and the invitation was sent to all through the e-ips online groups; thus, IToP undergraduate/postgraduate sections were created, which is being expanded to make it user-friendly.

The training of psychiatry teachers for undergraduates and postgraduates should be conducted in all the states of India by various universities and/state/zone/central Indian Psychiatric Society biannually/annually. Endowment funds can be created for such proceeding. Much emphasis can be given at national conference by exclusive symposia and workshop for training psychiatry teachers. Research in this area, including impact of such efforts, can be initiated. Thus, a systematic approach can be devised for psychiatry teachers training from time to time considering the Indian medical curriculum and aligning it with needs of national mental health plans and programs. For challenges that are unique to India, teachers of psychiatry will continue to play important role in preparing future doctors for national mental health services.

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