NMC Guidelines for Competency-Based Training Programme For MD Psychiatry

The National Medical Commission (NMC) has released the Guidelines For Competency-Based Postgraduate Training Programme For MD In Psychiatry.

The purpose of PG education is to create specialists who would provide high quality health care and advance the cause of science through research & training.

A postgraduate specialist having undergone the required training should be able to recognize the health needs of the communit, should be competent to handle medical problems effectively and should be aware of the recent advances pertaining to his specialty. The post graduate student should acquire the basic skills in teaching of medical/para-medical students. She/he is also expected to know the principles of research methodology and modes of consulting library.

The purpose of this document is to provide teachers and learners illustrative guidelines to achieve defined outcomes through learning and assessment. This document was prepared by various subject-content specialists. The Reconciliation Board of the Academic Committee has attempted to render uniformity without compromise to purpose and content of the document. Compromise in purity of syntax has been made in order to preserve the purpose and content. This has necessitated retention of "domains of learning" under the heading "competencies".

SUBJECT SPECIFIC LEARNING OBJECTIVES

The primary goal of the MD course in Psychiatry is to produce a post graduate clinician able to provide health care in the field of Psychiatry. A physician qualified in Psychiatry, at the end of the course, should be able to diagnose and treat psychiatric disorders, take preventive and curative steps for the disease in the community at all levels of health care and qualify as a consultant and teacher in the subject.

At the end of the MD course in Psychiatry, the student should have able to:

• Understand the relevance of mental health in relation to the health needs of the country

• Ethical considerations in the teaching and practice of Psychiatry

• Identify the social, economic, biological and emotional determinants of mental health

• Identify the environmental causes as determinants of mental health

• Institute appropriate diagnostic, therapeutic and rehabilitative procedures to the mentally ill patient

• Take detailed history, conduct appropriate ethically valid physical examination and institute appropriate evaluation procedures to make a correct clinical diagnosis

• Perform relevant investigative and therapeutic procedures for the psychiatric patient

• Recommend appropriate laboratory and imaging examinations and interpret the results correctly

• Plan and deliver comprehensive treatment of a psychiatric patient using principles of rational drug therapy

• Plan rehabilitation of psychiatric patient suffering from chronic illness

• Clinically manage psychiatric emergencies efficiently

• Demonstrate empathy and humane approach towards patients and their families and respect their sensibilities

• Demonstrate communication skills of a high order in explaining management and prognosis, providing counseling and giving health education messages to patients, families and communities

• Develop appropriate skills to practice evidence-based psychiatry

• Demonstrate competence in basic concepts of research methodology and epidemiology

• Be aware of and take appropriate steps in the implementation of national mental health programs, effectively and responsibly

• Be aware of the concept of essential drugs and rational use of drugs

• Be aware of the legal issues in the practise of Psychiatry

• Be aware of the special requirements in the practice of Child and adolescent Psychiatry and Geriatric Psychiatry

o Research: The student should know the basic concepts of research methodology and plan a research project in accordance with ethical principles. S/he should also be able to interpret research findings and apply these in clinical practice. S/he should know how to access and utilize information resources and should have basic knowledge of statistics.

o Teaching: S/He should learn the basic methodology of teaching and develop competence in teaching medical/paramedical students, health professionals, members of allied disciplines (e.g. behavioural sciences), law enforcement agencies, families and consumers and members of the public.

SUBJECT SPECIFIC COMPETENCIES

By the end of the course, the student should have acquired knowledge (cognitive domain), professionalism (affective domain) and skills (psychomotor domain) as given below:

A. Cognitive domain

By the end of the course, the student should demonstrate knowledge in the following:

1. General topics:

1. The student should be able to demonstrate knowledge of basic sciences (Anatomy, Physiology, Biochemistry, Microbiology, Pathology and Pharmacology) as applied to Psychiatry.

2. The student should be able to explain aetiology, assessment, classification and management and prognosis of various psychiatric disorders (including psychiatric sub-specialities), and Neuroanatomy, Neurophysiology, Neurochemistry, Neuroimaging, Electrophysiology, Psychoneuroendocrinology, Psychoneuroimmunology, Chronobiology and Neurogenetics.

3. Acquire knowledge of delirium, dementia, amnestic & other cognitive disorders and mental disorders due to a general medical condition.

4. The student should be able to explain follow-up care of person suffering from chronic relapsing psychiatric ailments.

5. The student should acquire knowledge of emergency measures in acute crisis arising out of various psychiatric illnesses including drug detoxification and withdrawal.

6. The student should acquire knowledge of pharmacokinetics & pharmacodynamics of drugs involved in psychiatric management of patients.

7. The student should acquire knowledge of (a) normal child development and adolescence, mental retardation in children (b) learning & associated disorders and their management

8. The student should acquire knowledge and be able to explain mechanisms for rehabilitation of psychiatric patients.

9. The student should acquire knowledge of substance related disorders and their management.

10. The student should acquire knowledge of psychotic disorders, mood disorders, and anxiety disorders and their management

11. The student should acquire knowledge of sexual and gender identity disorders and their management.

12. The student should acquire knowledge of eating disorders and sleep disorders and their management.

13. The student should be conversant with recent advances in Psychiatry.

14. The student should be conversant with routine bedside diagnostic and therapeutic procedures and acquire knowledge of latest diagnostics and therapeutics procedures available.

15. The student should be conversant with various policy related aspects of Psychiatric practice in India (e.g. Mental Health Act, National Health Mental Health Programmes etc.).

16. The student should be conversant with research methodologies.

B. Affective Domain:

1. The student should be able to function as a part of a team, develop an attitude of cooperation with colleagues, interact with the patient and the clinician or other

colleagues to provide the best possible diagnosis or opinion.

2. The student should always adopt ethical principles and maintain proper etiquette in dealings with patients, relatives and other health personnel

3. The student should demonstrate respect for the rights of the patient including the right to information and second opinion.

4. The student should develop communication skills to prepare reports and professional opinion as well as to interact with patients, relatives, peers and paramedical staff, and for effective teaching.

C. Psychomotor domain

At the end of the course, the student should acquire the following clinical skills and be able to:

•  become an expert in good history taking, physical examination, mental state examination, and able to establish rapport and counsel family members and patients on scientific basis. choose the required investigations for both short and long term management.

At the end of the course, the student should be able to:

1. Obtain a proper relevant history, and perform a humane and thorough clinical examination including detailed mental state examinations using proper communication skills.

2. Arrive at a logical working diagnosis and differential diagnosis after clinical examination.

3. Order appropriate investigations keeping in mind their relevance and cost effectiveness and obtain additional relevant information from family members to help in diagnosis and management.

4. Identify psychiatric situations calling for urgent or early intervention and refer at the optimum time to appropriate centres.

5. Write a complete case record with all necessary details.

6. Write a proper discharge summary with all relevant information.

7. Obtain informed consent for any examination/procedure.

8. Perform clinical audit.

9. Must be able to perform modified Electroconvulsive therapy (ECT).

The student, at the end of the course should be able to perform independently, the following:

1. Conduct detailed Mental Status Examination (MSE)

2. Cognitive behaviour therapy

3. Supportive psychotherapy

4. Modified ECT

5. Clinical IQ assessment

6. Management of alcohol withdrawal

7. Alcohol intoxication management

8. Opioid withdrawal management

9. Delirious patients

10. Crisis intervention

The student must be able to demonstrate approach to patient with variety of clinical presentations including following symptoms:

1. Auditory hallucinations

2. Visual hallucinations

3. Pseudo hallucination

4. Seizures true and pseudo seizure

5. Panic attack

6. Manic symptoms

7. Behavioural symptoms of schizophrenia

8. Catatonia

9. Delirium

10. Malingering

The student, at the end of the course should be able to perform under supervision, the following:

1. Behaviour therapy

2. Opioid intoxication management

3. Genetic counselling

4. Family therapy

The student, at the end of the course should be able to assist the expert in the following:

1. Interpersonal therapy

2. Management of suicide attempt

Syllabus

Course Contents:

No limit can be fixed and no fixed number of topics can be prescribed as course contents. He is expected to know the subject in depth; however emphasis should be on the diseases/health problems most prevalent in that area. Knowledge of recent advances and basic sciences as applicable to his/her specialty should get high priority. Competence in managing behavioural problems commensurate with the specialty must be ensured.

The student must acquire knowledge in the following:

Theoretical concepts:

1. Functional and behavioural neuroanatomy

2. Neurophysiology and Neuro-chemistry

3. Neuro-imaging

4. Electrophysiology (including chronobiology, electroencephalogram, etc

5. Psychoneuroendocrinology

6. Neurogenetic disorder

7. Classification In Psychiatry

8. Theory of personality and personality disorders

9. Abuse (Physical / Sexual) or Neglect Of Child /Adult

10. Adjustment Disorder

11. Anxiety Disorders (including Panic Disorder, Agoraphobia, Phobias, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, etc).

12. Case-Presentations (including History Taking, Neurological Examination, Mental Status Examination etc.).

13. Child Psychiatry (including Learning Disorders, Motor Skills Disorder, Communication Disorders, Pervasive Developmental Disorders (Autistic Disorder, Rett's Disorder, Childhood Disintegrative Disorder, Asperger's Disorder), Attention-Deficit/Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, Pica, Tic Disorders, Elimination Disorders, Separation Anxiety Disorder, Selective Mutism, Reactive Attachment Disorder of Infancy or Early Childhood, Stereotypic Movement Disorder, etc.)

14. Community psychiatry

15. Consultation-Liaison Psychiatry

16. Culture Bound Syndromes

17. Dissociative Disorders (including Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, Depersonalization Disorder, etc.

18. Eating Disorders (including Anorexia Nervosa, Bulimia Nervosa, etc.)

19. Electro-Convulsive Therapy

20. Emergencies In Psychiatry

21. Emotional Intelligence

22. Ethics In Psychiatry

23. Factitious Disorders

24. Forensic and Legal Psychiatry (including Indian Lunacy Act, Mental Health Act, Persons with Disability Act, Narcotic Drugs and Psychotropic Substance Act)

25. Impulse-Control Disorders (including Intermittent Explosive Disorder, Kleptomania, Pyromania, Pathological Gambling, Trichotillomania, etc

26. Learning – Theories

27. Memory

28. Mental Retardation

29. Miscellaneous: Non-compliance, Malingering, Antisocial Behaviour, Borderline Intellectual Functioning, Age-Related Cognitive Decline, Bereavement [including Death], Academic Problems, Occupational Problems, Identity Problems, Religious or Spiritual Problems, Acculturation Problems, Phase of Life Problems, Chronic Fatigue Syndrome, etc.)

30. Mood Disorders (including Depressive Disorders, Bipolar Disorders, Cyclothymic Disorder, etc.)

31. Movement Disorders (including Medication-Induced Movement Disorders, etc)

32. Organic Psychiatry (including Amnestic Disorders, Catatonic Disorder, Cerebrovascular Disorders, Delirium, Dementia, Endocrine Epilepsy, Head Injury, Headache, HIV – AIDS, Infections, etc.

33. Neuropsychology (including Psychological Features of Cerebral Disorders, Clinical Assessment etc.)

34. Pre-Menstrual Dysphoric Disorder

35. Post-Partum Psychiatric Disorders

36. Psychodynamics

37. Psychology (Clinical)

38. Psychometry/ Psychodiagnostics

39. Psychopharmacology

40. Psychosis (including Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Brief Psychotic Disorder, Shared Psychotic Disorder, etc).

41. Psychosomatic Disorders

42. Psychotherapy

43. Sexual And Gender Identity Disorders (including Sexual Desire Disorders, Sexual arousal Disorders, Orgasmic Disorders, Sexual Pain Disorders, Vaginismus, Paraphilias, etc)

44. Sleep Disorders (including Insomnia, Narcolepsy, Breathing-Related Sleep

Disorders, Circadian Rhythm Sleep Disorders, Parasomnias, Nightmare Disorder, Sleep Terror Disorder, Sleepwalking Disorder, etc.)

45. Somatoform Disorders (including Somatization Disorder, Undifferentiated Somatoform Disorder, Conversion Disorder, Pain Disorder, Hypochondriasis, Body Dysmorphic Disorder, etc.)

46. Statistics/Research Methodology

47. Stress and related disorders

48. Stupor

49. Substance Related Disorders (including Alcohol-Related Disorders, Amphetamine-Related Disorders, Caffeine-Related Disorders, Cannabis- Related Disorders, Cocaine-Related Disorders, Hallucinogen-Related Disorders, Inhalant-Related Disorders, Nicotine-Related Disorders, Opioid- Related Disorders, Phencyclidine-Related Disorders, Sedative-, Hypnotic-, or Anxiolytic-Related Disorders, etc.)

50. Suicidemanagement and medico-legal aspect

51. Transcultural Psychiatry

52. Rehabilitation of psychiatric patients

53. Geriatric Psychiatry

The student may know the following:

1. Psychiatry rating scales

2. Epidemiology

3. History of Psychiatry

4. Mental Health Issues in Women

5. Mind – the evolving concepts

6. Placebo Effect

7. Psychosurgery

TEACHING AND LEARNING METHODS

Teaching methodology

1. Lectures: Lectures are to be kept to a minimum. They may, however, be employed for teaching certain topics. Lectures may be didactic or integrated. Didactic lectures are of least importance; small group discussion such as seminars, journal clubs, symposia, reviews and guest lecturers should get priority for theoretical knowledge. Bedside teaching, grand rounds, structured interactive group discussions and clinical demonstrations should be the hallmark of clinical/practical learning. The student should have hands-on training in performing various procedures and ability to interpret various tests/investigations. Exposure to newer specialized diagnostic/therapeutic procedures concerning the subject should be given. Self learning tools like assignments and case base learning may be promoted.

The post graduate student should have knowledge of:

• Psycho-pharmacology and broadening the treatment options using medicines.

• Neuro-imaging techniques to understand behaviour and psychiatric illness.

• Community-Psychiatry.

• Functioning of psychiatric hospital.

Community Psychiatry should go beyond familiarization with the National Mental Health Programme. The post graduate student should have hands on experience with:

• G.P. Training Programme

• Organizing Mental Health Camps

• Carrying out Health Education Activities

• Forensic /Legal Psychiatry

• Integration of Mental Health Care with General Health Care

2. Thesis writing: Thesis writing is compulsory.

3. Research Methodology: The student should know the basic concepts of research methodology and biostatistics, plan a research project, be able to retrieve information from the library.

4. Teaching skills: The post graduate students shall be required to participate in the teaching and training programme of undergraduate students and interns.

5. Continuing Medical Education Programmes (CME): Each student should attend at least two CME programmes, in 3 years.

6. Conferences: The student should attend courses, conferences and seminars relevant to the specialty.

7. A post graduate student of a postgraduate degree course in broad specialties/super specialties would be required to present one poster presentation, to read one paper at a national/state conference and to present one research paper which should be published/accepted for publication/sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the postgraduate degree examination.

8. Seminars: There should be a weekly seminar in which the PG students present material on assigned topics in rotation. It should be followed by discussion in which all trainees are supposed to participate. Generally the topics covered should be those that supplement the formal teaching programme.

9. Case Conference: A case conference should be held every week where a PG student prepares and presents a case of academic interest by rotation and it is attended by all the members of the Department.

10. Psychosomatic Rounds: This is a presentation of a case of psychosomatic illness, or a medical illness with pronounced psychiatric problems. It should be held weekly in collaboration with various departments and attended by the faculty and the PG students of psychiatry and the concerned Department.

11. Research Forum: There should be a monthly meeting of one hour each in which the PG students present their plan of research as well as the report of the completed work of their projects. The other research scholars/staff in the department also may participate in it. The faculty, PG students and the non-medical professionals should make critical comments and suggestions.

12. Journal Club: A monthly meeting of Journal club should be held in which a senior PG student presents a critical evaluation of a research paper from a journal. All PG students are expected to attend.

13. Case presentations: All new in-patients and outpatients cases should be routinely reviewed with one of the Consultants. In addition, the PG student is required to present case material at routine rounds and other case conferences. Senior PG students will conduct evening classes on clinical topics.

14. Extra-mural activities: The post graduate students are encouraged to attend certain academic activities in allied subjects held outside parent department e.g. seminars/lectures held at Departments of Sociology, Psychology, Neurology etc.

15. Psychotherapy tutorials: These should be held in small groups supervised by a consultant, in which a case is presented by a PG student and psychotherapeutic management discussed.

16. Rotation:

Clinical Postings

• A major tenure of posting should be in General Psychiatry. It should include care of in-patients, out-patients, special clinics and maintenance of case records for both in and out patients.

• Exposure to the following areas should be given :-

Schedule of clinical postings for M.D Psychiatry *(36 months)

Area/ Specialty

Ward and OPD (Concurrent)                               18 months

Neurology                                                             2 months

Emergency Medicine/ Internal Medicine              1 month

Consultation Liaison Psychiatry                          3 months

Psychiatric hospital and Forensic Psychiatry      1 month

Clinical Psychology                                             1 month

Addiction Psychiatry                                            3 months

Child and Adolescent Psychiatry                         3 months

Community psychiatry                                         2 months

Elective posting                                                   2 months (as per choice in the same Institute)

* The stated duration can be subjected to minor modifications depending on available resources

# Exposure to community based services should be integral to various postings.

Applicable only for trainees in General Hospital Psychiatric units: Facilities for these need to be arranged.

The post graduate student in Psychiatric hospitals would have extended period of exposure to consultation - liaison psychiatry and other medical specialties. Exposure to community based services should be integral part of various postings. The post graduate student shall be given full responsibility for patient care and record keeping under the supervision of the senior PG students and consultants. The post graduate student shall also take patients for psychological interventions in an individual as well as group setting. S/he must complete a minimum of 100 hours of supervised psychological interventions.

• Inter-Unit Rotation of posting

Inter-unit rotation in the department should be done for a period of up to one year (divided during the first year and third year while the post graduate student stays in the parent unit throughout the duration of his thesis work).

17. Clinical meetings:

There should be intra - and inter - departmental meetings for discussing the uncommon / interesting medical problems.

18. Log book:

Each student must be asked to present a specified number of cases for clinical discussion, perform procedures/present seminars/review articles from various journals in inter-unit/interdepartmental teaching sessions. They should be entered in a Log Book and signed by the authorized teacher and Head of Department.

19. The Department should encourage e-learning activities.

During the training programme, patient safety is of paramount importance, therefore, skills are to be learnt initially on the models, later to be performed under supervision followed by performing independently. For this purpose, provision of clinical skills laboratories in medical colleges is mandatory.

ASSESSMENT

FORMATIVE ASSESSMENT, ie., assessment during the training

Formative assessment should be continual and should assess medical knowledge, patient care, procedural & academic skills, interpersonal skills, professionalism, self directed learning and ability to practice in the system.

Quarterly assessment during the MD training should be based on:

1. Journal based / recent advances learning

2. Patient based /Laboratory or Skill based learning

3. Self directed learning and teaching

4. Departmental and interdepartmental learning activity

5. External and Outreach Activities / CMEs

The student to be assessed periodically as per categories listed in postgraduate student appraisal form (Annexure I).

SUMMATIVE ASSESSMENT, ie., at the end of training

The summative examination would be carried out as per the Rules given in POSTGRADUATE MEDICAL EDUCATION REGULATIONS, 2000.

The examination shall be in three parts:

1. Thesis

Thesis shall be submitted at least six months before the Theory and Clinical / Practical examination. The thesis shall be examined by a minimum of three examiners; one internal and two external examiners, who shall not be the examiners for Theory and Clinical examination. A post graduate student shall be allowed to appear for the Theory and Practical/Clinical examination only after the acceptance of the Thesis by the examiners.

2. Theory Examination:

There shall be four papers each of three hours duration.

Paper I: Basic Sciences as related to Psychiatry

Paper II: Clinical Psychiatry

Paper III: Psychiatric theory and Psychiatric specialties

Paper IV: Neurology and General Medicine as related to Psychiatry

3. Clinical/Practical and Oral/viva voce examination should consist of:

• Presentation of long case of Psychiatry

• Neurology short case

• A short case Psychiatry

• Viva –voce

Due importance should be given to Log Book Records and day-to-day observation during the training.

Recommended Reading Books (latest edition)

1. Kaplan and Saddock's Comprehensive Text Book of Psychiatry

2. Kaplan and Saddock 's Synopsis of Psychiatry

3. Fish Clinical Psychopathology

4. Lishman's Organic Psychiatry, The Psychological consequences of cerebral disorder

5. Clinical practice guidelines of Psychiatric disorders in India

6. Stahl Psychopharmacology

7. Oxford text book of Psychiatry

8. Mental Health Act, Person with Disability Act (India)

9. Lowinson et al -Substance Abuse-A Comprehensive Textbook

10. Galanter and Klebert-Textbook of Substance Use Treatment

Journals

03-05 international Journals and 02 national (all indexed) Journals