Bril.J. Psychiat. (ig7@), 126, 550—5

Objectives

and Training By PETER

in Psychiatry

BROOK

Summary. The recommendations on postgraduate training made by the World Health Organization, the Nuffield Provincial Hospitals Trust and the Royal Medico-Psychological Association are examined in the light of modern concepts of educational objectives. In this country no well defined, specific, assessable and detailed objectives have yet been formulated for postgraduate training

in psychiatry.

The need for clearly setting out the aims and

trainee

@

is expected

to become,

and should

not

be dependent on whatever educational facilities are available, or on an existing curriculum, which might well be the product of hard bar gaining in committee. Failure to formulate

objectives of training in precise and clear form has in recent years been widely, but by no means universally, accepted. As Michael Simp

son ( I 972) points out, stated aims and objectives objectives overtly is to run the risk of including are all too often so vaguely stated that they are merely ‘¿the educational equivalent of “¿mother the trivial or inappropriate and ofomitting what hood―

and

“¿patriotism― : no

one

@could disagree with them, but Lan put them to much use'.

but

a

no one

beast

is desirable.

at all

not

elements standing),

Just where does British psychiatry stand in this respect at this moment ? What guidelines do we possess, whether as teachers or trainees, educators

or students,

and are the guidelines

Learning,

but

. . . cognitive psychomotor

and affective that

as Miller

unidimensional

(attitudes

the statement

must

a

(1967)

says ‘¿is

constellation

(knowing and (professional

of

under skills),

and values) . It means be in terms

of what

a

student is to become'.

in

such a form that programmes and curricula @anbe constructed from them? Before answering these questions it would be useful to look more closely at some general

Objectives must be relevant to what is to be practised and, equally important, must be seen by the trainee to be relevant, otherwise motiva

@considerations

Objectives

about

TREORETICAL

lion, and in consequence

objectives.

need to be precisely

clearly

defined, and in order to be meaningful they must be expressedin behaviouralterms,that is they need to describe performance which is

both observable and measurable; diffuse global objectives which lack precision or clear meaning can no longer be regarded as adequate. Object ives should be formulated in terms of what the * Part

of the

material

in this

paper

is contained

be capable

learning,

will suffer.

of realization

within

the limitations of time and resources available. Objectives need to be framed so that they are

CONSIDERATIONS

The goals of training

must

need

understandable

by the

to be described

they are capable of measured. Jason (I 973) postulates

in such being

student.

They

a way assessed

two types

ives ; terminal and enabling. Terminal

that and

of object

objectives

describe a desirable piece of behaviour and are usually complex to the extent that they cannot

be obtained

in an

M.D. thesis submitted to the University of London in May 1974. 350

in one instructional

step but only

after a period

of steps which build on each other.

It is these

latter

that

are

termed

enabling

BY PETER BROOK

objectives. To take a concrete example : the terminal objective might be ‘¿to obtain sufficient data

from

a patient

to describe

the

mental

55'

goals and the distance

they have yet to go'. This

type offeedback is provided by an evaluation of how the student's performance matches up to the

state'. Among the enabling objectives would be: the ability to conduct an interview with a patient

desired behavioural tion may be termed

systematically

more usual ‘¿judgemental'evaluation

; a knowledge

of affective

and their modes of expression;

changes

a knowledge

of

concepts of abstract or concrete thinking ; an understanding ofwhat constitutes an hallucina tion and the sensory modalities in which it could

be expressed ; a knowledge of tests which will examine concentration, short- and long-term memory

and orientation.

A number against

of criticisms

the behavioural

have been levelled

definition

the fail-or-pass

as found in

examination.

Miller reminds us that ‘¿instructionalmethods that

actively

involve

students

in learning

are

more likely to be effective than those that do not'. However, different teaching methods may have little difference of cognitive domain and yet may have differing effects on attitudes.

One example from psychiatry conducted

of objectives.

objectives. Such an evalua ‘¿diagnostic'rather than the

in Edinburgh

is an experiment

(Walton,

i@j73) when

It has been argued, for example, that since only what is trivial can be defined its objectives in consequence are constrictive and restrictive.

an attempt was made to discover the best method for teaching psychiatry to medical

J ason,however,believesthat ‘¿any expectationa

lectures, another

faculty

combination

member

may have can be formulated

as

an objective'. High levels ofintellectual activity, such as creativity, can be defined. Again fears have been expressed that using a hierarchy or taxonomy

of objectives

(Bloom,

1956) can lead

to fragmentation and atomization, so that the wood may be lost for the trees, but Bloom's taxonomy

allows

for setting

objectives

at various

levels of generality depending on the topic. A related criticism is that precisely defined beha vioural

objectives

are

inappropriate

activity such as psychiatry complex

and

subtle.

It may

for

an

where issues may be indeed

be difficult

to specify all behaviours described, but certain high priority objectives can still be formulated while specific detail can merge during training. Miller (1967) has formulated a cybernetic cycle for educational programmes. Learning experiences

should

develop

out

of objectives,

while methods of evaluation should be directly related to these learning experiences and in turn these should encourage continuing re-examina tion of educational objectives. Miller goes on to make a number of points about educational process.

Learning

is enhanced

by

feedback;

learning will also be ‘¿speeded and its retention made more secure when students are regularly provided with diagnostic information about their strengths and weaknesses, the extent to which they have progressed towards educational

students,

one of three

groups

being

taught

by

by seminars and a third by a

of the two approaches.

The

three

procedures were equally effective in the cogni tive and psychomotor spheres, but in the area of attitudes seminars had a more definite and significant impact than the other methods. What was striking was the students' marked preference for the seminar method of teaching, which derived from their increased opportunity to relate personally to their teacher and to patients. Objectives must reflect the structure and needs of the society in which the psychiatrist has been trained and will spend his working life,

as well as the ideals of the profession. In the light of the changing practice of psychiatry and of, changes in society, Miller (1967) neatly summarises present-day requirements thus: ‘¿objectives must

be

reviewed

continuously,

for it is only if they are dynamic and responsive that they will serve the student, the faculty, the institution

statement

and

society.

All of which

says

that

a

of objectives is not an end in itself, a

set of words to which a faculty may pledge allegiance and then forget, but an integral part

of the educational reference

progress,

a key point

of

for the total programme'.

In this country programmes of training have been greatly influenced by recommendations made by three bodies, the World Health Organi zation (W.H.O., 1963), the Nuffield Provincial Hospital Trust (1967) and the Royal Medico

OBJECTWES

552 Psychological

Association

at

ference on Post-graduate

the

AND TRAINING

i 969

Psychiatric

Con

Education

(Russelland Walton,i970). Becausethesethree sets of recommendations fluenced thinking about gramme

of training

be examined

Trainees,

contain,

each

In

RECOMMENDATIONS

OF 1962

An expert Committee on Mental Health met in 1962 and published its report the following year (W.H.O., 1963). The Committee recom

felt,

1966 the Nuffield

working

Tim WORLDHEALTHORGANIZATION'S

Committee

should

be

them

THE NUFFIELD PROVINCIAL HOSPITAL'S TRUST REPORT

will

in detail.

the

encouraged, at the very least, to educate selves to prepare for a teaching role.

have profoundly in what an ideal pro

should

IN PSYCHIATRY

parties

Trust

on vocational

set up three training,

one of

which concerned itself with vocational training for the psychiatric services (Nuffield Provincial Hospital Trust, I 967). The psychiatric working party, in considering the objectives of training,

felt that the consultant psychiatrist should have a good understanding of the disciplines related to psychiatric practice, including ‘¿general followed by a year or more of ‘¿differential medicine . . . neuroanatomy, physiology, bio and pharmacology; psychology, training', either in one of the sub-specialties or, chemistry for those not specializing, to allow them to sociology and social administration ; theoretical mended an initial period, lasting at least three years, of what they termed ‘¿broadtraining',

enlarge

their knowledge

or to engage in research.

foundations

of psychiatry

and

medical

psy

These recommendations clearly foreshadow those of the Royal Commission on Medical

chology'. From the point of view of practical experience they considered that the consultant

Education

should

(1968)

five years

later.

During

the

three years of broad training the trainee should have ‘¿opportunitiesof seeing adult patients and child patients (including the mentally sub normal) and their families in various treatment settings—in-patient, out-patient, day hospital, and in the community treatment services'. The

offering prophylatic Committee stressed

that the trainee would need the closest possible contactwith his community, that he shouldhave a sound knowledge ofthe principles and procedures ofpsychotherapy, experience in groups and corn munities and ‘¿thoroughfamiliarization with the technique of community care in general'.

In outlining details the Committee recorn mended instruction in psychiatric interviewing techniques at the very beginning, supervised clinical experience, and at the same time instruction in the biological and social sciences and other theoretical bases for psychiatry.

These included neuroanatomy, neurophysiology, neuropathology, medical psychology, medical sociology, genetics, epidemiology and chronic diseases and, for psychiatry proper, the history of psychiatry, clinical phenomena of the psychiatric illness, dynamic processes in psychia tric illness,

clinical

subnormality, psychiatry

neurology,

psychosomatic

and therapeutic

child psychiatry,

disorders,

techniques.

social

be able to deal with

the chronically

disabled,

the acutely

ill and

should be flexible in

his deployment of all methods should give scope and support

of treatment, and to other members

of the psychiatric team working both inside and outside the hospital. These objectives were summarized thus: ‘¿the psychiatrist should at the completion ofhis training be widely experienced in dealing with all the common problems of psychiatry.

He should

have a sound

knowledge

of several disciplines in so far as they impinge on the theory and practice of psychiatry. He should be aware of advances in other fields relevant

to his subject.

In clinical

work, admini

stration and teaching, he should be able to make use of evidence deriving from several different sources in making considered and valid judge

ments'. To achieve these objectives, any scheme for vocational training would, in the working party's opinion, need to offer adequate clinical experi ence, tutorial teaching in the theory and practice of psychiatry and, for general psychiatrists, periods

of

experience

and

tuition

fields such as child psychiatry,

in

special

psychotherapy,

forensic psychiatry, subnormality and clinical neurophysiology. Adequate academic teaching in disciplines related to psychiatry would need to be available, and university departments

BY PETER

should offer help with work on special topics and research projects. The working party concluded that ‘¿trainingmust equip for full and effective collaboration with other allied workers'. Ti@ I969 CONFERENCE 1971, the Royal Medico-Psychological

In

Association

laid

down

guidelines

as

to

BROOK

2. Psychological and social sciences. 3. Child development.

4. Personality: variation and development. 5. Socialstructure 7. Clinical

are still based

on recommendations

Psychological

Association

and

the Association

for the Study ofMedical Education (Russell and Walton, 1970). This conference was the first one of its sort that the Royal Medico-Psycho logical

Association

smaller, tric

had

less ambitious,

education,

Institute (Davies

had

mounted,

although

conference been

of Psychiatry and Shepherd,

sponsored

six years

a

on psychia by

the

previously

1964).

Seven panels were set up, each charged with producing a working paper on its assigned topic; this was circulated before the meeting and was introduced by the panel who had prepared it and

then

topics

opened

were

: the

to general demand

discussion.

for

psychiatrists

entrants to psychiatric training; objectives ; methods of teaching programme

formation

(curricula)

requirements

of proficiency;

for the future.

general objectives of psychiatric stated thus : ‘¿knowledgefor mastery of the subject; clinical, scientific skills; and habits of attitudes

of mind

educational psychiatry; ; assessment

of results of training—standards organizational

by which

The ; the

The

training were a theoretical personal and thought and

to use such know

ledge and skills in the best interests of the patient, his family and the community'. More specifically, the areas of knowledge were given thus: i. The

that

neurological

sciences

is neurophysiology,

relevant

to psychiatry,

neuroanatomy

and

biochemistry. The Panel thought it likely that as medical education became more compre hensive and relevant these would be dealt with at postgraduate level by ‘¿selected advanced seminars

on the growing

points

of these

sciences'.

and psychopathology.

knowledge.

This would

cover

‘¿every age

from infancy to the senium' and range widely to cover not only the psychoses, functional and organic, but also the neuroses, disorders of personality, sexual deviations, the addictions,

the

made at the Conference on Postgraduate Psychiatric Education held in March 1969 under the joint auspices of the Royal Medico

and social administration.

6. Psychodynamics

content of clinical experience. These have recently been brought up to date (Royal College of Psychiatrists, ‘¿973), but the most detailed guidelines

553

psychosomatic

disorders

and emotional and injury.

consequences

and

the

psychological

of physical illness

8. Psychopharmacology. In the domain of skills these were seen as including clinical ones for which a wide range of clinical experience was desirable, therapeutic skills including

pharmacological,

social, psycho

therapeutic and the ability to exercise leadership in the therapeutic team, teaching skills and administrative skills. It was emphasized how the trainee must understand and know how psychiatrists practise in different settings and ‘¿he should be prepared to work as a member of the team which will necessarily include others of a different background and training and who have acquired well-developed skills which are by no means those which are the psychia trists's prerogative'. (Trethowan, 1970).

The panel's recommendations as a clearly formulated

taxonomy mulated

of educational by

Bloom

One example development

cannot be seen

set of objectives and

using a

objectives his

as for

colleagues

(1956).

of a set of objectives of a set of skills,

for the

together

with

methods of assessment and the settings in which specialty skills are taught, is given in Langsley et al. (i973). These objectives were prepared for first-year mental health pro fessionals being trained by the Department of Psychiatry of Pacific Medical Centre. The contrast objectives

between these clearly formulated and those prepared by the panel is a

striking one. The panel dealing with programme formation (Shepherd, 197oa) took as its yardstick the structure of the training programme for the University of London

Psychological that

time

system,

Academic

Medicine.

covered

psychology,

Diploma

This examination

the biology

sociology

in

at

of the nervous

and

genetics,

OBJECTIVES AND TRAINING

554

IN PSYCHIATRY

clinical psychiatry and clinical neurology, and included a dissertation on a piece of original work. The contents of postgraduate training

in a behavioural analysis

of the

programmes

required

of an effective

in psychiatry

I . Basic

sciences.

were classified

These

were

thus:

regarded

as

divisible ‘¿intotwo large categories : the biological group, including neuroanatomy, neurophysiology, neuroendocrinology, neuro psychology,

ethology,

pharmacology,

neurochemistry,

psychopharmacology,

psychosocial

group,

neuro and

including

the

psychology,

sociology, anthropology, epidemiology and demography. Psychology is a bridge discipline between extends

areas

and

these into

groups. the

of social

On

the one hand

indisputably

non-biological

and

on the other

modern

educational

hand

neuropsychology

it

formance,

I 970b)

. No

thus

there

of adequate was a need

knowledge,

further

skills

and

psychiatrist

progress

seems

per for an

attitudes

(Shepherd, to have

been

made in this country since that time, although proposals have been made for a preliminary research study (Cawley, R.H., personal comm unication). An analysis needs to be made of the knowledge, skills and attitudes required not only of the consultant, but also of other pro fessionals in the mental health field, general practitioners, nurses, social workers and psycho logists, so that the unique contributions of each

can be determined and behavioural objectives can be formulated for them. Even without such

psychology,

the techniques

of

research

are often

to

clearly stated

closer

description

and

physiology than to psychology in the narrower sense'.

it ought

training

to be practicable

set of objectives

conforming

to Jason's

to produce

a

for psychiatric criteria

; that this

general psychiatry, during which time the trainee would receive instruction in the areas specified in paragraph I 29 of the Royal

can be done has been demonstrated in the out line syllabus for the training of community psychiatric nurses produced by the Joint Board of Clinical Nursing Studies (i 974). The Royal College of Psychiatrists should now address

Commission's Report psychiatry, neurology

for the training of psychiatrists.

2.

The

clinical

components.

These

(1968), training in child and psychotherapy.

However, the panel cautioned risks of ‘¿dogmaticand one-sided indoctrinations'

included

in the last, and

against the theoretical

recommended

that psychotherapy should be taught ‘¿within a broad framework of the behavioural sciences during the years of general professional training' (Shepherd, I97oa).

itself urgently

[email protected]&ar@rrs

Clare, both of whom, quite independently, suggested the

topic of this paper. REFERENCES

BLOOM, B. S. (ed) (1956) Taxonomy ofEducation

There can be no doubt, after reading the literature on postgraduate training in psychiatry and most particularly the recent memorandum on Educational Programmes produced by the Royal College of Psychiatrists (iç@7@), that in no well defined,

specific,

Domain.

DAVIES, D. L. (5968)

CONCLUSIONS

assessable

and detailed objectives meeting Miller's or Jason's criteria have been formulated for post graduate training in psychiatry. This point emerged in the topic on assessment at the 1969 Conference. It was touched on in passing in the Chairman's working document (Walton, 1970), and was forcefully underlined by one of the contributors to the discussion, when it was pointed out that psychiatry was quite lacking

a set of objectives

I am grateful to Professor Gerald Russell and Dr. Tony

I : Cognitive

this country

to producing

New

York:

Psychiatric

David

education

In Studies in Psychiatty (eds. Shepherd,

Objectives.

McKay.

and

training.

M. & Davies,

D.). London: Oxford University Press. JASON, H.

(i@7@) Instructional

objectives

and

priorities.

In Mental Health Ethwationin the New Medical Schools, pp. 79-87

(cdi. Langsley,

D., McDermott,

J. F. &

Endow, A.). San Francisco : Jossey-Bass. LANGSLEY, D. G.,

MCDERMOTT,

J.

F. & ENTELOW, A. J.

(cdi.) (ig7@) Mental Health Education in the Xew Medical

Schools.San Francisco :Jossey-Bass. LANcET MILLER,

(1971) G.

E.

Editorial: (1g67)

‘¿Collegecapers', Educational

science

ii, 587—8. and

education

for medicine. British Journal of Medical Education, i, 156-9. NUFFIELD PROVINCIAL HosPITALS Training in Medicine. Report

TRUST (1g67) Vocational of the Working Party o'@

Vocational Training for Psychiatric Services. London: Nuflield Provincial

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RoYAi@Cow@nssIoNON MEDICALEDUCATION (i g68) Report.Command

Paper 3569.London: H.M.S.O.

BY PETER BROOK RoYAl. MEDIco-PsYCHoLoGICAL.

@

AssociATioN (1971) Edu

MEDICO-PSYCHOLoGICAL

ASSOCIATION

(1973)

Memorandum on educational programmes for trainees in general psychiatry. News and Notes. Supplementto the British Journal of Psychiatry.October 1973, pp. 3—5. RUSSELL, G. F. M. & WAVrON, of

Psychiatrists.

Postgraduate

Proceedings

of

Education.

the

Conference

SHEPHERD, M.

(cdi. Russell, G. & Walton,

Chairman's

working

document

of Psychiatrists, pp. 82-92 (eds. Russell, G. & Walton,

H.). London: R.M.P.A.

document

R.M.P.A

A Critical Approach.

document

‘¿Assessment'. In The Trainingof Psychiatrists, pp. 97—114(eds.Russell,G. F. & Walton, H.). London:

R.M.P.A. —¿

(197oa)

H.). London:

Walton, H.J.) London: R.M.P.A. WALTON, H. J. (1970) Chairman's working

on

‘¿Programme Formation (Curricula)'. In The Training

of working

Tanmow@se, W. H. (i97o) Educational objectives. In The Training of Piatrists (eds. Russell, G. F. &

London:

R.M.P.A.

Discussion

SIMPSON, M. A. (1972) Medical Education. London : Buttcrworths.

H. J. (i@@o) The Training

Psychiatric

(197ob)

‘¿Assessment'.In The TraiithsgofP@ychiatrirts,pp. 17-I&

cational programmes for trainees in psychiatry. British Journal of Ps@hiatry,ii8, 693-5. ROYAL

555

SHEPHERD, M.

(1973)

Research

in

psychiatric

education.

Psychiatric

Qjtarterly, 46, 532—42.

Woaw

[email protected] ORGANIZATION(1963)

Psychiatrists.

Trairang of

12th Report of the Expert Committee on

Mental Health. W.H.O. Tech. Rep. Ser. 252. Geneva@ W.H.O.

A synopsis of this paper was published in the November 1974 Journal.

Peter Brook, M.D., F.R.C.Psych.,Consultant Psychiatrist, Warley Hospital, Brentwood, Essex, CMx4 5HQ (Received 25 July 1974)