Senior house officer training in child and adolescent psychiatry

As educators, we are being encouraged to use adult learning theory when organising training. This paper describes the development of a course originally for trainees in psychiatry and the shift from a traditional model of training to one that incorporates new approaches to learning (Spencer & Jordan, 1999). We describe the move away from a didactic delivery of information to a multi-professional, skills-based approach to the training of general psychiatric trainees.

The course

For a number of years, all the senior house officers (SHOs) in the Mersey region have attended, during their child and adolescent psychiatry placement, a weekly course, based at the Alder Hey Hospital. This enables the trainees to access teaching in child and adolescent psychiatry that would be difficult to provide in each individual placement. In the past, the course depended on traditional teaching methods such as lectures and case presentations. The main aim was to impart to trainees theoretical knowledge and the emphasis was academic.

The course has always been valued by trainers and trainees and the level of trainee attendance is high. However, the content of the course has changed over time in response to feedback from the trainees and greater awareness of their training needs. Trainees are no longer viewed as passive receivers of knowledge but are active participants in the learning process.

Currently, a specialist registrar (SpR) facilitates the programme, which runs for six months, taking place weekly and lasting for two hours. The SHO trainers all have a teaching input to the programme. The SpR is supervised, in respect of the teaching, by the speciality tutor for child and adolescent psychiatry who also coordinates the course. The specialty tutor also has responsibility for organising the child and adolescent psychiatry lectures for the MRCPsych course and this ensures that duplication is avoided.

Developments

Two main areas of development have been the introduction of multi-professional training and skills-based learning. The importance of the support that trainees get from the group and the significance of the teaching experience for the specialist registrar, have also been recognised as important benefits of the change of approach.

Multi-professional training

Multi-professional education and training has been advocated as a way of improving medical training (Cox, 1996) and fostering the essential collaboration of medicine with allied health personnel (World Federation for Medical Education, 1994). The course has included non-psychiatric participants for the last three years. This has brought a number of benefits and some potential difficulties.

Currently, the group consists of the seven psychiatric trainees plus two, or occasionally three, non-psychiatrists. The professional backgrounds of the non-psychiatrists have been primarily nursing and social work. The non-psychiatrist participants typically have a greater range and longer duration of experience than the psychiatric trainees. This greater experience benefits the whole group and the psychiatric trainees are exposed to a wide range of approaches which enriches the discussion and opens up possibilities of different teaching approaches for the programme facilitator.

The group is able to address problems encountered by group members during their day to day work. A wider discussion of possible solutions can take place because of the input from non-psychiatrist members. For example, on one occasion the group discussed how an angry adolescent had left a family meeting. The input from the non-psychiatric group members was helpful. They were able to suggest a number of different ways of managing angry young people using their own experience. These could then be tried out - using role-play - by group members, within the safety of the group.

The non-psychiatric group members benefit from the more academic approach of the psychiatric trainees and develop a better understanding of the aetiology of child mental health disorder and the theoretical basis for treatment approaches.

The challenge for the programme facilitator is to manage the group in such a way that the trainees do not feel threatened by the greater experience of the non-psychiatrists and the non-psychiatrists do not feel disadvantaged by the trainees' greater academic knowledge and scientific background. The facilitator also has to balance the demand from some psychiatric trainees for exam-focused information against the needs of the whole group.

Skills-based training

General psychiatric trainees coming into child and adolescent posts can often feel de-skilled. Although this is addressed by good supervisors within individual placements, it seemed a good opportunity to try to tackle this as part of the course. We considered the skills that a trainee might need when starting a child and adolescent placement and aimed to see if we could facilitate the trainees developing these skills as part of the course programme.

Case material provides the starting point for most sessions, but these are organised as discussions rather than presentations. From the beginning of the course, the participants are encouraged to bring video-tapes of their work or the work of the team. We have found that trainees are very skilled in the mental state examination of an adult and interviewing individuals but are not used to dealing with a family interview or assessing the mental state of a child. Therefore, how to manage a family interview, how to talk to a child and how to carry out the mental state examination of a child are all dealt with early on in the course programme. Teaching from the supervising consultants covering these areas is provided. The video or other case material then acts as the basis for discussion about the process, which is observed by the group members. The process is emphasised, with the aim of the discussion to consider issues such as, how to engage a family, how to involve all family members in the discussion, how to help a family tell their story, when it might be best to separate family members and other skills which experienced practitioners take for granted. Skills can then be practised within the group using techniques such as role-play. There are opportunities for case discussion considering diagnostic issues, but this takes place in the middle of the programme during the sessions that deal with psychiatric disorder.

Trainees can also become isolated from their SHO peer group during their child and adolescent placement and child and adolescent mental health service teams can add unintentionally to the trainees' lack of confidence in their ability to contribute to the work of the team. We have found the course to be a valuable source of peer support and as group cohesion builds a safe place for the trainees to develop and practise skills. Psychiatric trainees are often in placements with the non-psychiatric participants on the course. This can be a valuable source of support and means shared experiences can be used and skills develop in joint working (Funnel, 1995).

Role of the SpR

The SpR is central to the smooth and effective running of the course and has responsibility for arranging the programme and facilitating the group. In line with the new paradigms in learning, it has been recognised that trainers need to be taught to teach. Giving higher specialist trainees opportunities to learn how to teach is being recognised as an important component of higher training (Cottrell, 1999). We have found the organisation and teaching of this course to be a valuable learning experience for higher trainees. The SpRs who have facilitated the programme have been enthusiastic about the change in the content and enjoyed skills teaching as well as the academic component. They are keen to get feedback from the participants and see this as important information leading to improvement of the course programme rather than criticism of their teaching.

Conclusion

We consider this course to be an important component of SHO training and would like to propose that there should be more opportunities for psychiatric trainees to receive training in multi-professional groups. This area does require further evaluation and research (Campbell & Johnson, 1999). The change of emphasis to a more skills-based course has had benefits for trainers and trainees and has made teaching more enjoyable for all concerned. With the publication of the learning objectives for SHO placements in child and adolescent psychiatry, it is a good time to reassess the way in which training is delivered.