The Impact of the Functional Model of Service Delivery on Undergraduate Psychiatry Education

The Impact of the functional model of service delivery on undergraduate psychiatry education

Dr Sherlie Arulanandam1 Dr Livia Yip1 Avon and Wiltshire Mental health partnership NHS trust, Bristol, United Kingdom.

Corresponding author

Dr Sherlie Arulanandam Speciality registrar year 6

Department of Liaison Psychiatry Clinic 7, Level 2, Queen’s Building, Bristol Royal Infirmary BS2 8HW

Tel: 0117 342 2778 / 2777 Fax: 0117 342 2776 Mobile: 07891826212 Email address – [email protected]

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The Impact of the functional model of service delivery on undergraduate psychiatry education

An increasing number of mental health trusts in the UK are replacing the geographically sectorised model of service delivery with a functional one ( 1). The Psychiatric Trainees Committee of the Royal College of Psychiatrists acknowledges that the breadth of clinical experience may be limited in the functional model unless core training in various service settings is ensured (2).

There is no doubt that medical students’ educational experience of psychiatry plays a great role in determining whether they choose a career in psychiatry (3). Additionally, the changes in the organization of mental healthcare, including more treatment in the community, preventive psychiatry and psychosocial interventions, challenge conventional roles in medicine and this may deter doctors who favor working in hospital settings (4). It is therefore crucial to generate interests in psychiatry in medical students doing their placement and to provide them with access to a variety of clinical experiences.

Several studies have looked into the impact of the functional model on psychiatric training but no such studies have been conducted on undergraduate medical students. All the recent changes in service delivery can have a detrimental effect on students’ placement and in turn recruitment of doctors in psychiatry. Therefore it is important for us to evaluate the current undergraduate training system in psychiatry.

Avon and Wiltshire Partnership Mental Health NHS Trust (AWP) provides undergraduate training to third year medical students studying in the University of Bristol. Each year, four batches of students are allocated to various geographical areas within AWP to do an eight weeks placement in psychiatry. In North Bristol, the model of service delivery was changed to a functional one in late 2011. Students doing their psychiatric placement in North Bristol are allocated to a site tutor, an educational supervisor and a mentor. The main teaching sites in North Bristol are Southmead Hospital and Blackberry Hill Hospital. However, students are required to travel across the whole of Bristol in order to have a wide variety of clinical experiences and to complete their logbook.

Medical students raised concerns on their learning experience with the functional model of service delivery through informal feedback and a decision was made to conduct a survey to look into the impact of this model on undergraduate psychiatric training.

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The Impact of the functional model of service delivery on undergraduate psychiatry education

Aim:

To evaluate the impact of functional model of service delivery in psychiatry on undergraduate psychiatric training.

Methods: We designed a survey with thirteen questions for the purpose of our study. The questions were either qualitative or quantitative. The survey was approved by the educational leads in AWP and the University of Bristol. We then set up the survey online and invited all the 28 students who did their psychiatric placement in North Bristol in late 2011 to mid 2012 to complete the survey. A total of three invitations were sent by email to each student. Students were asked to answer all of the thirteen questions. The answers of the survey were then collected and analyzed using simple statistics.

Results:

19 out of 28 (68%) students completed the survey.

Among the 19 students who completed the survey, they interviewed 144 patients personally during their placement. Of the 144 patients, 114 (79.2%) of them were inpatients and 26 (18.1%) of them were outpatients (Table 1).

Table 1

No. of Patients Average No. of Mode Patients Seen Inpatients 114 6 6 & 7 (4/19) Outpatients 26 1.4 2 (6/19) Total 144 7.6 8 (5/19)

Out of the 144 patients interviewed by the students, 29 (20.1%) were interviewed under observation by medical staff. Most students (10/19) had one observed interview only and on average, they had 1.5 observed interviews during their placement. Students were given feedback for all of these observed interviews.

The minimum required number of case based discussions was two. Among the 19 students, 14 (73.7%) of them were able to complete the required number of case based discussions. Two (10.5%) of them were unable to do so and another two (10.5%) of them said they were “just about” to complete the required task. Interestingly, one student (5.3%) was unsure whether he/she had completed the required number of case based discussions.

The majority of students (15/19 students; 79%) rated their overall inpatient experience as satisfactory to good. “Friendliness of staff” was the only area to achieve excellent and “willingness of patients to be interviewed” was the only area that got rated as very poor (Table 2).

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The Impact of the functional model of service delivery on undergraduate psychiatry education

Table 2

Very Poor Poor Satisfactory Good Excellent Experience on 0 21.1% 63.2 15.8% 0 Ward (4) (12) (3) Friendliness of 0 0 21.1% 57.9% 21.1% Staff (4) (11) (4) Approachability 0 0 42.1% 57.9% 0 of Staff (8) (11) Willingness of 5.3% 26.3% 36.8% 31.6% 0 Patients to be (1) (5) (7) (6) Interviewed Willingness of 0 21.1% 26.3 52.6% 0 Staff to Teach (4) (5) (10)

Regarding to the time students spent on travelling and organizing their placement, many students felt that they spent too much time travelling between various sites. On an average week, they spent five hours travelling. They also said that they spent nearly three to five hours trying to organize various clinical opportunities.

In terms of whether the placement was useful in preparing the students for their clinical examination, nearly 79% of them felt that it was useful. They found the discussion or role-playing sessions with their educational supervisor, tutor or peers most helpful. On the contrary, the found formal teaching sessions and workshops and reading textbooks or journals the least helpful.

In terms of satisfaction with the placement, 56% of students were satisfied but 15% of them were not.

In the survey, we asked the students how things could change to make the placement better. Below are some of their suggestions.  A shorter but more work intensive placement would perhaps improve the motivation to go and do things every day and also provide a more even spread of other units through out the year.

 Spending less time organizing extra activities. More time to discuss cases we found difficult.

 Clinic slots should be pre-booked for medical students to put their names down.

 More bedside teaching/time to spend with psychiatrists discussing cases (while clinics provide a good opportunity to observe there is often little time to practice skills and discuss). History taking and practice interviewing with actors would be helpful at the beginning of the course rather than in the middle.

 Easier access to clinical experience

 More ward-based teaching. Group academic lectures at the start of the placement (e.g. all in week 1) to base clinical learning on in the following weeks.

 Less travelling. Less administration

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The Impact of the functional model of service delivery on undergraduate psychiatry education

Discussion: Overall, 56% of students were satisfied with their placement and nearly 79% of them found it useful in preparing for their clinical examination at the end of the placement. It is clear from the results that students would find it more helpful if they could spend less time travelling to different sites in order to have all their clinical experiences and also less time in organizing their clinical activities. We are aware that the psychiatric placement is the only one among all other clinical placements that require students to organize their own learning timetable. Some of them find this extra responsibility hard to manage. We feel that although organizing all or more clinical activities for the students might save them time, it is important to find a balance between student led or self-directed learning and teacher led learning. It would be useful for students to master the skills of adult learning as early as possible in their medical career.

The willingness of patients to be interviewed was rated quite low. This could be due to the reduction in hospital beds, meaning fewer patients would be available for students to interview on the ward. Students have to “compete” among each other in order to interview patients. From the patients’ perspectives, they might not want to be interviewed by students over and over again.

About 21% of students rated the willingness of staff to teach and their experience on the ward as poor. We feel that the overall inpatient experience could be greatly influenced by the willingness of staff to teach. We believe that psychiatrists in general, regardless of their grade, have a duty to teach and most are willingly to do so provided they have time. With the current teaching programme, students will just go to the ward and see patients at random times. It could be that when the students visited the ward, none of the staff were available to teach them as they were busy with their own clinical work. This problem could be resolved if students are given allocated times to interview patients on the ward as well as an allocated staff (nurse/doctor) to discuss the patients with them. Having said that, students can always discuss cases with their mentors and educational supervisors if they cannot do so on the ward.

Limitations:

There are some limitations of the survey. The reliability of the results may be reduced by a potential response bias. The survey might be completed by mainly students with positive or negative experiences. The results would be more reliable if the response rate was higher. The fact that we only invited students who did their placement in North Bristol to complete the survey means that our results may not be as valid and generalizable in other geographical sites within AWP.

Recommendations:

From our results, we think the major problems with the functional model of service delivery in undergraduate psychiatric training is the limited access to patients and exposure to a variety of clinical experiences. In view of this, we suggest that the following should be considered:

1) Incorporate the use of stimulated patients in tutorials/workshops. 2) Students should be exposed to both complex and non-complex cases. 3) Each student should be given and allocated slots for out-of-hours experience, including emergency assessments. 4) Students should be encouraged to organize their own clinical activities to promote self-directed learning. Support from educational supervisor and mentors should be provided where necessary.

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The Impact of the functional model of service delivery on undergraduate psychiatry education

Conclusion:

Research often focuses on the impact of current psychiatric practice in postgraduate psychiatric training but the impact in undergraduate psychiatric training is often overlooked. Medical students are important as they are our future doctors and emphasis should be given to their training needs. In order to make psychiatry as an appealing career option for them, we need to ensure that their undergraduate experience in psychiatry is positive, educational and enjoyable.

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The Impact of the functional model of service delivery on undergraduate psychiatry education

Notes on authors

Dr Sherlie Arulanandam is a ST6 registrar in Bristol. She is an associate unit tutor for medical students and an honorary senior lecturer at Bristol University.

Dr Livia Yip is a ST6 registrar in Bristol. She is very interested in teaching and been an active tutor and honorary senior lecturer at Bristol University.

Acknowledgements

The help of Dr Geoff van der Linden, Associate director of medical education, Avon and Wiltshire partnership NHS trust is gratefully acknowledged.

Declaration of interest

None

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The Impact of the functional model of service delivery on undergraduate psychiatry education

References

1. Golam Khandaker,Srinivasarao Cherukuru,Claire Dibben and Manaan Kar Ray- From a sector- based service model to a functional one: qualitative study of staff perceptions - The Psychiatrist (2009) 33: 329-332

2. Royal College of psychiatrists - Postgraduate training in psychiatry -Essential information for trainees and trainers - July 2008

3. Maidment R, Livingston G, Katona C, McParland M, Noble L - Change in attitudes to psychiatry and intention to pursue psychiatry as a career in newly qualified doctors: a follow-up of two cohorts of medical students. Med Teach 2004; 26: 565-9.

4. Ania Korszun, Nishan Dharmaindra,Valsraj Koravangattu and Kamaldeep Bhui -Teaching medical students and recruitment to psychiatry: attitudes of psychiatric clinicians, academics and trainees - The Psychiatrist (2011) 35: 350-353

Table 1

No. of Patients Average No. of Mode Patients Seen Inpatients 114 6 6 & 7 (4/19) Outpatients 26 1.4 2 (6/19) Total 144 7.6 8 (5/19)

Table 2

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