Brazilian psychiatry medical residency programs: critical analysis

Abstracts

INTRODUCTION: The last decades have witnessed great advances in the field of Psychiatry, and the study of this discipline has become more complex. Advances in neurosciences as well as in classic studies on psychopathology, psychopharmacology, psychotherapy and neurology have helped psychiatric diagnosis and treatment. Nevertheless, Brazilian psychiatric medical residency programs did not adapt themselves to this new reality. OBJECTIVES AND METHOD: Based on the recommendations of the World Psychiatry Association (WPA), we analyzed residency programs in Brazil and also in other countries in America and Europe. Based on the WPA's Core Training Curriculum for Psychiatry, we propose a minimum curriculum for psychiatry residency in Brazil. DISCUSSION: Most of the programs had in common: duration of at least three years; full-time neurology training lasting at least one month; training in psychopathology, psychopharmacology, psychotherapic theories, psychiatric emergencies, among other courses; teaching and practice in several psychotherapic traditions; human development (childhood, adulthood and elderly); alcohol and drugs; free time for personal development (so that the trainee can engage in therapy, studies or research projects). CONCLUSION: Brazilian psychiatric residency programs are not up to date in relation to the training criteria proposed by the WPA (and adopted in several countries, including in Latin America). Based on the WPA model, residency programs in Brazil need to ensure that psychiatric residents will be provided the minimum necessary requirements for good quality training, respecting regional differences.

Medical residency; psychiatry; curriculum; quality; postgraduate; psychotherapy; teaching

INTRODUÇÃO: A psiquiatria evoluiu muito nas últimas décadas e seu estudo tornou-se, conseqüentemente, mais complexo. Os avanços em neurociências, aliados aos estudos clássicos de psicopatologia, psicofarmacologia, psicoterapia e neurologia, influenciaram grandemente o diagnóstico e o tratamento psiquiátricos. Apesar disso, a residência em psiquiatria no Brasil não se adequou a essa nova realidade. OBJETIVOS E MÉTODO: Partindo das recomendações da World Psychiatry Association (WPA), pesquisamos na Internet programas de residências brasileiros e de países das Américas e Europa. Comparamos nosso programa com as recomendações e dados do Institutional Program on the Core Training Curriculum for Psychiatry da WPA e propusemos um currículo mínimo para a residência em psiquiatria. DISCUSSÃO: Na maioria dos programas pesquisados, alguns pontos se destacam: duração mínima de 3 anos; estágio integral em neurologia por no mínimo um mês; conteúdo programático contendo psicopatologia, psicofarmacologia, teorias psicoterápicas, emergências psiquiátricas entre outras disciplinas; ensino e prática das diversas linhas psicoterápicas; abrangência das várias etapas da vida (crianças, adultos e idosos); álcool e drogas; espaços livres de que o residente pode dispor para sua formação (terapia, estudo ou pesquisa). CONCLUSÃO: O modelo brasileiro de residência em psiquiatria encontra-se defasado em relação à formação proposta pela WPA (observada em diversos países, mesmo latino-americanos). A residência necessita, seguindo modelo referenciado pela WPA e respeitando as diferenças regionais de cada escola, prover o mínimo para uma boa formação do psiquiatra.

Residência médica; psiquiatria; currículo; qualidade; pós-graduação; psicoterapia; ensino

INTRODUCCIÓN: La psiquiatría evolucionó bastante en las últimas décadas y su estudio se hizo, consecuentemente, más complejo. Avances en las neurociencias, aliados a los estudios clásicos en psicopatología, psicofarmacología, psicoterapia y neurología influenciaron en gran medida el diagnóstico y el tratamiento psiquiátricos. Sin embargo, el programa de pasantía psiquiatría en Brasil no se adecuó a esta nueva realidad. OBJETIVOS Y MÉTODO: Partiendo de recomendaciones de la World Psychiatry Association (WPA), investigamos en internet programas de pasantía brasileños, de países de las Américas y Europa. Comparándolos con las recomendaciones y datos del Institutional Program on the Core Training Curriculum for Psychiatry de la WPA, propusimos un currículum mínimo para el programa de pasantía en psiquiatría en Brasil. DISCUSIÓN: En la mayoría de los programas investigados, se destacan algunos aspectos: Duración mínima de tres años; práctica integral en neurología por periodo mínimo de un mes; programa incluyendo psicopatología, psicofarmacología, teorías psicoterapéuticas, emergencias psiquiátricas entre otras asignaturas; enseñanza y práctica de las diversas corrientes psicoterapéuticas; cobertura de las varias etapas de la vida (niños, adultos y ancianos); alcohol y drogas; periodos libres de los cuales el médico residente puede disponer para su formación complementaria (terapia, estudio o investigación); entre otros puntos importantes. CONCLUSIÓN: El modelo brasileño de pasantía en psiquiatría está desfasado en relación a la formación propuesta por la WPA (observada en diversos países, incluso en Latinoamérica). La pasantía necesita, siguiendo el modelo referenciado por la WPA y respetando a las diferencias regionales de cada escuela, suministrar las bases mínimas para una buena formación del psiquiatra.

Programa de pasantía; psiquiatría; currículo; calidad; postgrado; psicoterapia; enseñanza

ORIGINAL ARTICLE

Psychiatry residency in Brazil: a critical analysis

Programas de pasantías en psiquiatría en Brasil: un análisis crítico

Bruno Mendonça Coêlho^I; Marcus Vinicius Zanetti^I; Francisco Lotufo Neto^II

^IResident, School of Medicine, Universidade de São Paulo, Brazil

^IICoordinator, Psychiatry Residency, School of Medicine, Universidade de São Paulo, Brazil

^{Correspondence}

ABSTRACT

INTRODUCTION: The last decades have witnessed great advances in the field of Psychiatry, and the study of this discipline has become more complex. Advances in neurosciences as well as in classic studies on psychopathology, psychopharmacology, psychotherapy and neurology have helped psychiatric diagnosis and treatment. Nevertheless, Brazilian psychiatric medical residency programs did not adapt themselves to this new reality.

OBJECTIVES AND METHODS: Based on the recommendations of the World Psychiatry Association (WPA), we analyzed residency programs in Brazil and also in other countries in America and Europe. Based on the WPA's Core Training Curriculum for Psychiatry, we propose a minimum curriculum for psychiatry residency in Brazil.

DISCUSSION: Most of the programs had in common: duration of at least three years; full-time neurology training lasting at least one month; training in psychopathology, psychopharmacology, psychotherapic theories, psychiatric emergencies, among other courses; teaching and practice in several psychotherapic traditions; human development (childhood, adulthood and elderly); alcohol and drugs; free time for personal development (so that the trainee can engage in therapy, studies or research projects).

CONCLUSIONS: Brazilian psychiatric residency programs are not up to date in relation to the training criteria proposed by the WPA (and adopted in several countries, including in Latin America). Based on the WPA model, residency programs in Brazil need to ensure that psychiatric residents will be provided the minimum necessary requirements for good quality training, respecting regional differences.

Keywords: Medical residency, psychiatry, curriculum, quality, postgraduate (graduate), psychotherapy, teaching.

RESUMEN

INTRODUCCIÓN: La psiquiatría evolucionó bastante en las últimas décadas y su estudio se hizo, consecuentemente, más complejo. Avances en las neurociencias, aliados a los estudios clásicos en psicopatología, psicofarmacología, psicoterapia y neurología influenciaron en gran medida el diagnóstico y el tratamiento psiquiátricos. Sin embargo, el programa de pasantía psiquiatría en Brasil no se adecuó a esta nueva realidad.

OBJETIVOS Y MÉTODOS: Partiendo de recomendaciones de la World Psychiatry Association (WPA), investigamos en internet programas de pasantía brasileños, de países de las Américas y Europa. Comparándolos con las recomendaciones y datos del Institutional Program on the Core Training Curriculum for Psychiatry de la WPA, propusimos un currículum mínimo para el programa de pasantía en psiquiatría en Brasil.

DISCUSIÓN: En la mayoría de los programas investigados, se destacan algunos aspectos: Duración mínima de tres años; práctica integral en neurología por periodo mínimo de un mes; programa incluyendo psicopatología, psicofarmacología, teorías psicoterapéuticas, emergencias psiquiátricas entre otras asignaturas; enseñanza y práctica de las diversas corrientes psicoterapéuticas; cobertura de las varias etapas de la vida (niños, adultos y ancianos); alcohol y drogas; periodos libres de los cuales el médico residente puede disponer para su formación complementaria (terapia, estudio o investigación); entre otros puntos importantes.

CONCLUSIÓN: El modelo brasileño de pasantía en psiquiatría está desfasado en relación a la formación propuesta por la WPA (observada en diversos países, incluso en Latinoamérica). La pasantía necesita, siguiendo el modelo referenciado por la WPA y respetando a las diferencias regionales de cada escuela, suministrar las bases mínimas para una buena formación del psiquiatra.

Palabras clave: Programa de pasantía, psiquiatría, currículo, calidad, postgrado, psicoterapia, enseñanza.

INTRODUCTION

The satisfaction of being accepted in a psychiatry residency program is perhaps comparable, in terms of intensity, to the despair felt by the resident when realizing the amount of information that needs to be faced. And worse: there will be only two years to assimilate everything. It is hard to understand how one of the fastest growing medical specialties can be covered in such a short period of time.

Psychiatry, which until the 1930s was restricted to the custodial institutionalization of patients, has acquired tremendous complexity.¹ At that time, with the beginning of electro-convulsive therapy, a new era of treatment was starting. The development continues with the introduction of neuroleptic drugs in the mid-twentieth century, culminating today in an extensive treatment arsenal at the service of physicians.

Several new fields have had a major impact on psychiatric treatment and diagnosis. These encompass new knowledge being continuously generated through intensive research in neurosciences, involving the fields of molecular biology, neurobiology, psychopharmacology, epidemiology, new perspectives in genetics, new methods in the functional study of the nervous system (including functional nuclear magnetic resonance, positron emission tomography, magnetic encephalography and high-resolution electroencephalography), reconceptualization of certain theories and psychotherapy approaches, advances in cognitive neurosciences, better understanding of psychosocial phenomena and treatment, more attention to ethical issues and other significant scientific advances.² This influence will grow substantially in the future, making the theoretical study of psychiatry an increasingly harder task.

The growth in the available amount of information concerning psychiatric diseases can be illustrated by the fact that 1,800 journals are currently indexed in the Institute for Scientific Information (ISI) PsycINFO alone.³ In addition, good psychiatric practice still requires deep knowledge in psychopathology and psychotherapies, among so many concurrent sciences, whose practical application demands closely supervised training.

The Madrid Declaration (World Psychiatric Association, WPA) confirms this notion: "It is the duty of psychiatrists to keep abreast of scientific developments of the specialty and to convey updated knowledge to others."⁴ The document also reveals the WPA's concern with ethical aspects and the well-being of patients, not to mention the evident emphasis on the excellence in knowledge and interdisciplinarity. The Declaration states that "Psychiatrists serve patients by providing the best therapy available consistent with accepted scientific knowledge and ethical principles. Psychiatrists should devise therapeutic interventions that are least restrictive to the freedom of the patient and seek advice in areas of their work about which they do not have primary expertise."⁴

In addition, according to the World Health Organization (WHO), mental disorders affect over 450 million people and account for 12.3% of the causes of disease and incapacity. Even if the authorities pay due attention to this problem, the number of people affected by mental disorders will reach 562 million in 2020.⁵ This will result in an impressive excess demand for psychiatric services, already observed in Brazil today. The current shortage of psychiatrists will worsen in the coming decades, resulting in the need to train general practitioners to provide basic psychiatric care and to have non-medical professionals provide formal psychotherapy.⁶ All this shows that psychiatry is undergoing fast and continuous growth, which consequently translates into increased demand.

This situation prompted us to question the basis upon which the Brazilian medical psychiatry residency programs are founded. It became clear to us, following an analysis of the curricula of the residency programs of some of the major schools of Medicine in the world, that some aspects are essential for the training of psychiatrists. The teaching of psychotherapy and neurology, the involvement in research projects and the classic study of psychopathology and psychopharmacology must, more than ever, receive attention in this new model. Rather than being a utopia, the growth in knowledge required by the practice of psychiatry makes the effort for change a real need.²

DISUCSSION

As stated earlier, we believe that several disciplines converge to shape psychiatry. After all, this specialty, with its peculiarities, cannot be reduced to merely a medical science. In addition to Medicine, other human sciences have a major role in the understanding of the human being and its biopsychosocial essence. Thus, a medical residency program in psychiatry must incorporate these elements aiming at the best training of physicians.

In the world, the concern with the teaching of psychiatry is not new. The WPA, in collaboration with the World Federation for Medical Education (WFME), has designed a proposal/model for teaching of Psychiatry at the undergraduate level which has already been implemented in several medical schools in the world.²

The teaching and the quality of psychiatry residency programs are also the concern of organizations such as the WPA and WFME. In 1997, a new core psychiatry curriculum began to be designed. This effort was completed in 2002. In this document, the WPA declares that "training and education are the essential links between the creation of new knowledge via research and investigation efforts and the dissemination and application of new knowledge via teaching and educational activities." The potential challenge posed by the growth of knowledge to some countries, especially developing nations, is also considered. This occurs because the changes that are necessary for the adaptation of curricula would be more easily achieved in developed countries. The need for an inter-relation between undergraduate and graduate curricula is also evident.²

Considering this scenario, there is a clear need for a critical analysis of psychiatry residency programs as they are currently structured in Brazil. The problem of excess information to which the residents are currently submitted, associated with the scarcity of time for adequate training, is a poignant problem calling for immediate action. In the current format, which entails two years of studies, the training in psychiatry in Brazil has blanks that will only be filled (if at all) after a long period of professional practice. In addition, the insufficient training forces professionals to look for extracurricular training, outside the academic environment, whose quality cannot be guaranteed by medical societies. The WPA establishes a minimum of three years of training for general psychiatry residents. The Association also recommends additional training in subspecialties such as forensic psychiatry, old age and child psychiatry, among others.²

We will now show the importance of a harmonious interaction between these different branches in the study of modern psychiatry, so as to support the implementation of the new model proposed. For that, we will focus on the points which we consider as the most important and which require urgent intervention.

On psychotherapies

The concept of health proposed by the WHO in 1946, in which health is defined as a "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,"⁷ must be adopted by psychiatry as a milestone in its therapeutic conception. This concept assumes that the biological, social and other aspects of psychic life cannot be dissociated. The teaching of an integrated model, involving psychopharmacology and psychotherapy, is necessary in residency programs, since it contemplates the benefits of associating these two modalities, which are becoming increasingly evident in the literature. This synergy only brings benefits to thepatient. In addition, it erases, in part, the "artificial separation of the psychosocial and biological domain in psychiatry."⁸ This separation is largely responsible for one of the fallacies of the current model.

The new discoveries in the fields of genetics and psychopharmacology, among others, have revolutionized the study of psychiatric diseases. However, this scientific development, as advanced as it is, has not been sufficient to solve some of the most important problems of humanity. It has also been insufficient to define more than chemical reactions that occur in a given organ in the body. The interaction between these reactions and the complex processes of mental elaboration is still far from being elucidated. The artificial separation of psychological and social factors has become a huge obstacle to the true understanding of mental and behavioral disorders. In fact, these disorders are similar to many physical diseases, since they result from the complex interaction of several factors. For many years, scientists have discussed the relative importance of genetic factors vs. environmental factors in the development of mental and behavioral disorders. The current scientific evidence indicates that mental and behavioral disorders result from genetic and environmental factors, or, in other words, from the interaction of biology with social factors.⁵

"The brain does not simply reflect the deterministic unfolding of complex genetic programmes, nor is human behaviour the mere result of environmental determinism. Prenatally and throughout life, genes and environment are involved in a set of inextricable interactions. These interactions are crucial to the development and course of mental and behavioural disorders."⁵

A promising fact is the demonstration, for example, that behavioral therapy for the treatment of obsessive-compulsive disorder results in alterations in brain function. These alterations can be observed with the use of imaging techniques, and are similar to the changes that occur in association with drug therapies.⁹

The development of the so-called more biological areas of psychiatry cannot serve as an excuse to decrease the dynamic focus represented by psychotherapies in the process of residency training. This would be nonsense, because since we are dealing with problems whose origin is multifactorial, or even unknown, the solution must also have multiple facets. In addition, the psychiatrist, more than any other medical specialist, must learn to deal with the transference and countertransference mechanisms that are part of our practice. The only way of doing this is through the study of psychotherapies. It is also important to keep in mind that the study of therapies should not be restricted to the classical psychoanalysis model. It is necessary to have a general vision of the many treatment modalities and respective theoretical grounds. Currently, the mastery of interpersonal, behavioral and cognitive therapy techniques is important.

On the integration with neurology

Psychiatry and neurology share many features, beginning with the organ which is the focus of activity in these two specialties: the brain. Although many times the mechanisms of professional action in these two areas are not similar, the interrelation between them is huge. A good example of a model-disease supporting this interrelation is epilepsy, especially epilepsies affecting the temporal lobe. The Epilepsy Project at the Universidade de São Paulo Psychiatry Institute (PROJEPSI-IPq-HCUSP) is a good example of this close relationship between neurology and psychiatry. According to Marchetti,¹⁰ the association between epilepsy and mental disease reported by some epidemiological studies points to an unequivocal increase in the prevalence of mental disorders in children and adults with epilepsy (between 30 and 50%) in relation to the general population. That author also mentions that the prevalence of mental disorders is clearly higher when one moves from population-based studies to studies assessing groups of patients with treatment-resistant epilepsies.

In addition to the relations described above, others can be established. The association of mental and behavioral disorders with neural disturbances occurring inside specific circuits has been demonstrated. Changes in the maturation of neural circuits, in schizophrenia, can produce detectable changes in the pathology of cells and gross tissues, which result in the incorrect or maladaptive processing of information.¹¹

Another example is Alzheimer's disease, classified in the ICD-10 as a mental and behavioral disorder, since it is characterized by the progressive decline of cognitive functions such as memory, thought, understanding, calculus, language, the capacity to learn and discrimination.⁵

On psychiatry research

There is an understanding, on the part of some investigators, that it would be important for the resident to be involved in research projects. Rubin & Zuromski, for example, consider that research should be an integral part of residency programs.⁶

The arguments that support this hypothesis are based on the notion that this would prepare the resident to make a critical judgment of the research to which s/he has access. Even if this type of knowledge should be transmitted in undergraduate years, the role of residency, in this case, would be to compensate for a deficiency that is obvious in the training of physicians in general. In addition, this experience could be extremely valid as a preparation for later studies. This view is also in accordance with the Madrid Declaration, which states that "psychiatrists trained in research should seek to advance the scientific frontiers of psychiatry."⁴

If residency programs were longer, research-related courses could be offered as optional disciplines (such as statistics and scientific methodology, for example). Such courses could even count as credit for a future stricto sensu graduate program. Residency programs could create favorable conditions for the resident to choose to continue his or her studies by entering a graduate program immediately after the completion of a residency program.

It is important to stress that this should be optional; it would be the choice of the resident to follow or not a research-oriented training.

On the need for "green areas"

During the period of undergraduate studies, some medical schools in Brazil (especially those implementing the module curriculum) have adopted the practice of "green areas," or activity-free gaps in the curriculum. These are moments during which students can rest, practice sports, dedicate themselves to extracurricular activities or to optional courses in the program. These gaps in the curriculum are necessary due to the high demands faced by the residents along the program. These would be moments in which the resident could even spend time on his/her own therapy, an activity stimulated by advisors. The importance of therapy is clearly shown in a study by Campbell,¹² demonstrating that the estimated prevalence of mental disorders among psychiatry residents ranges from 4 to 22%. That author suggests the need for a stronger commitment on the part of residency programs in terms of recognizing and responding to the emotional needs of residents.

Residency programs: Brazil and the world

When we set out to compare the residency programs in Brazil with those from other countries, we faced one major difficulty: the lack of information about the situation in Brazil. The electronic information concerning Brazilian universities is precarious in relation to other parts of the world, including other countries in Latin America. Almost none of the Psychiatry Departments in Brazil has a web page, and the websites dedicated to medical residency programs are even more scarce. In cases where such a web site is available, little information is provided concerning the curriculum and structure of the program. Also in the website of the National Council of Medical Residency, the agency in charge of medical residency in Brazil, there are no data referring to each program specifically.

However, even with the lack of details, it is possible to infer some information beyond the organization of the programs, which in Brazil is already behind. A major source of data concerning the situation in the world is the WPA website. This website provides references concerning the teaching of psychiatry, including the International Survey on Graduate Training in General Psychiatry, which collected information from 36 residency programs around the world.² It includes information about various countries, such as Azerbaijan, Malaysia, Canada, Nigeria, the United States and Argentina. None of the Brazilian residency programs were included in this survey.²

Looking at the Brazilian context, we are first faced with the duration of the residency programs, an information that is easily available and uniform across different institutions: 2 basic years. The situation is quite different around the world. According to data from the WPA, only 11.6% of the medical residency programs surveyed lasted two years.² In contrast, the usual duration in other countries is as follows: United States, 4 years; Canada, 5 years; United Kingdom, 3 years; Argentina, 3 to 4 years; Mexico, 4 years - just to mention a few examples. According to the WPA, 88.4% of the residency programs surveyed had a duration of more than 3 years (6 years in 7.7% of the cases).

We understand that in Brazil, a developing country, with a major deficiency in terms of the attention given to primary health, resources cannot be completely directed to train ultraspecialists and scientists. However, as the president of the Federal Council of Medicine had a chance to observe in his recent trip to Cuba, a medical training completely focused on social needs may result in professionals that are far from the ideal recommended by a "world medical society" (even in terms of differences), and therefore alienated from the new knowledge that continuously becomes available.¹³

When the curricula of several countries are analyzed, it is possible to observe a trend of acknowledging the importance of psychotherapy to the psychiatrist. Some programs recommend that the resident come into contact with the many modalities of psychotherapy; in some, such as the United States and Canada, it is suggested that this be done as a subspecialization. As an example, below are the courses related to the topic that are mandatory for all residents at the University of Columbia Psychiatry Department (New York, US): cognitive behavioral therapy, dialectical behavioral therapy, psychodynamic interviewing, clinical psychodynamics I, psychotherapy of severe personality disorders, techniques of psychotherapy I, clinical psychodynamics II, family therapy, supportive therapy, interpersonal therapy, group therapy, couples therapy, process seminar, erotic transference, demonstration of psychodynamic psychotherapy, psychotherapy of psychosis, brief dynamic therapy, comparative psychotherapies.¹⁴ This level of detail could perhaps be considered as exaggerated for our reality; but how many Brazilian training centers are apt to provide the minimal psychotherapy training?

Models such as those of the United States or Canada, including a year of residency in clinical medicine, intensive therapy and neurology, are probably very far from our current reality. On the other hand, the clinical complications of alcohol and drug addiction, the frequent co-morbidities of an aging populations, and the high prevalence of neuropsychiatric disorders, such as epilepsies and dementias, in the Brazilian population are certainly part of our reality. If we consider the WPA survey, which shows that in most programs there is a period, ranging from 1 to 6 months, dedicated to the teaching of internal medicine, we will see that, although distant, we should aim to reach this objective as soon as possible. In the case of neurology, this period is larger than 4 months in most programs.² This shows that knowledge in general medicine and neurology is very important for the psychiatrist. However, how many Brazilian psychiatrists are capable of performing a complete neurologic exam?

The situation is not different when it comes to the teaching of psychiatric emergencies. In 56.7% of the programs evaluated in the world, there is a period larger or equal to 6 months of training in this aspect. The same is true for child and adolescent psychiatry and geriatric psychiatry. In most universities around the world, these topics are not optional. Instead, they are part of the core curriculum of residency programs.²

As we have previously emphasized, the amount of theoretical information and practical abilities required for the good practice of psychiatry is huge and involves great complexity: we believe that our current model (2 years) not only excessively simplifies the entire theoretical basis that is essential for psychiatrists - it does not provide enough time for the adequate supervision of the practical abilities of residents.

CONCLUSION

The human brain, with its complexity, imposes, even to the most experienced individuals, continuous study and practice in the evaluation of its many subtleties. The psychiatrist, similarly to the neurosurgeon, approaches this delicate organ as part of the daily routine, with the difference being restricted to the instruments used and the fact that the psychiatric interview is still the only available diagnostic resource in most cases. Specialization stems from development, but, since the patient is whole, integration is required. For that, one needs time.

Taking into consideration the current limitation of the pedagogical and curricular model, with a consequent lack of responsibility on the part of institutions concerning the final product, we would like to propose a restructuring of the medical psychiatry residency programs in Brazil, starting with the minimal training time. Rubin & Zurosmski suggest that the residency programs in psychiatry should have flexible curricula, so as to easily incorporate the fast advances in diagnostic and therapeutic aspects into the training.⁶

However, despite the depth of all the debates, the analyses performed so far fail in one crucial aspect. There is no participation of the student, the resident, that is, of that individual who will ultimately be affected by all these proposals. The internal look of the target of this training process is equally important to formulate this new training paradigm. In addition, this prevents us from engaging in analyses which are not as efficient in practical terms as they seemed to be in theory due to the sheer lack of knowledge concerning the situation of residents. This is where we find the greatest difference between this and other works focused on the teaching process in medical residency programs. We stress, however, that we have no intention of providing all the answers for such a complex problem.

There must be a "unification of discourses" so as to avoid situations such as that described by Yudkowsky et al.¹⁵: a significant difference between the perspective of residents and program coordinators concerning the quality indicators of psychiatry residency programs. While the first judge as important "interpersonal relationships, academic resources and opportunities, curriculum, clinical resources and opportunities," the coordinators highlight "program administration, curriculum and clinical resources, quality of the institution, financial resources and individual preferences." All the relationships established in a residency program should take into account the opinions of all the actors involved in the process, so as to establish harmonious models.

Our proposal to remodel the medical psychiatry residency - taking into account regional differences - proposes the use of a high cutoff point for what should or should not be included in a residency program. We believe that we should not lower the standards because of a few residencies that do not have much to offer - quite on the contrary, we should try to ensure that all programs have the minimum to ensure an adequate training. This minimal training is essential to educate good psychiatrists, ready to deal with the problems they face every day. It is worth stressing that the intention is not to impose a curriculum, but rather to propose the minimum standards on which this curriculum would be structured. The final objective is to achieve professional excellence.

NEW PROPOSAL

As discussed along this article, it is necessary to have a medical residency model that meets the current needs of the candidate to become a psychiatrist. This model should contain a little of each of the points we have previously outlined, in addition to allowing sufficient flexibility so that the program can be adapted to the specific circumstances that appear every day, without neglecting the regional differences of each institution.

Thus, we propose the following guidelines, in accordance with those proposed by the WPA:

- Strengthen the theoretical and practical teaching of psychotherapies starting on the first year, including supervised clinical consultation, so that, at the end of the program, the psychiatrist will have a comprehensive view of all the existing psychotherapy modalities (psychoanalysis, psychodrama, cognitive and behavioral therapy, group therapies, couples therapy, child therapy, among others), in addition to having acquired the basic capacities to practice them.

- Encourage a practical internship in neurology (minimum of 6 months, as recommended by the WPA),² with emphasis on neurological semiology and topodiagnosis.

- Provide core theoretical knowledge on functional neuroanatomy, psychopharmacology, psychopathology and psychiatric emergencies.

- Underscore the learning of basic sciences (human growth and development, social and behavioral sciences, genetics and psychopharmacology).

- Provide core knowledge in semiology, classification of psychiatric diseases and disorders and child, adult and elderly psychopathology.

- Train the student to become competent in interviewing, communication and patient education, diagnostic tools (physical exam, lab tests, imaging exams, etc.) and treatments.

- Ensure that the resident become competent in the many forms of psychiatric therapy (psychopharmacotherapy, somatic treatment, psychotherapy, rehabilitation, electroconvulsotherapy, treatment of crisis or emergency situations, among others).

- Emphasize the medical character in the promotion and prevention of mental health.

- Participate in the patients' psychosocial rehabilitation programs.

- Complete an internship in psychiatric nursing (both general nursing and specific nursing of the major groups of psychiatric pathologies) for at least 18 months.

- Participate in a psychiatric outpatient clinic during the entire residency, under adequate supervision, since the knowledge on diagnoses is crucial for the practice of psychiatry.

- Elaborate a program of specific outpatient clinics for each group of psychiatric disorders and various age groups starting in the second year of residency, including alcohol and drugs and forensic psychiatry (including exams and reports).

- Work in a psychiatric urgency service.

- Work in primary health units for at least 3 months.

- Provide notions of child, adolescent and elderly psychiatry.

- Participate in research projects.

- Offer optional courses at the university, which could be used as credits in a future stricto sensu graduate program.

- Stimulate the discussion of scientific articles.

- Organize courses on emergency care, such as advanced life support, taking into consideration the frequency of comorbidities in a population at risk for chronic diseases as well as the toxic potential of psychiatric drugs.

- Make the curriculum flexible enough to allow changes that may be necessary based on new information to be incorporated without a negative impact on the overall curriculum.

- Adapt the curriculum for each year to include "green areas" in which the resident has time for his/her own psychotherapy or other activity of his/her choice.

In addition, taking into consideration a 3-year residency program, we suggest that:

During the first year

The most important aspects in the training of psychiatrists should be emphasized in the first year - the basis of knowledge for the specialty, starting with the diagnostic and therapeutic study of psychiatric diseases. This should include the teaching of psychopathology, psychopharmacology, psychotherapies (all aspects), studies in basic neurology, and discussion of clinical cases. In addition, general clinical activities should be carried out, with psychotherapeutic consultation, nursing, duty and contact with psychotherapies. The "green areas," which could provide sufficient emotional vigor the next years, should not be forgotten. It is necessary to emphasize that the current model, which focuses on practical aspects rather than on theoretical elements, is valid; however, some theoretical points should be added to the program. The same is true for the practical training.

During the second year

During the second year of residency, the focus should be on some of the major groups of psychiatric disorders: schizophrenia, mood disorders, anxiety disorders, eating disorders, epilepsies, alcohol and drugs, interconsultation, forensic psychiatry, geriatric psychiatry and others. This is also the moment for involving residents in research projects and for studying neurology in more detail. The continuation of the work in a general clinic is important, as well as the continuous training in psychotherapies. It is important to remember that some activities should be carried out throughout the program, due to their relevance.

During the third year

During the third year, in addition to continuing the general clinic and furthering the study of psychotherapies, the resident should have internships in clinics not covered during the second year, including childhood psychiatry. At this point, the resident would have sufficient autonomy to provide care at primary health units, supported by his/her reference hospital. At the end of the program, the resident should be prepared to provide psychiatric care in an adequate manner.

Subspecialization

Specialization programs covering different fields should also be offered, having as pre-requisite the three basic years. Such specialization programs should focus on childhood psychiatry, forensic psychiatry, elderly psychiatry and psychotherapy, in tandem with the worldwide trend.

Acknowledgments

The authors are grateful for the support provided by Dr. Luiza Helena Vilas Bôas Russo, Luiza Epaminondas Barros and Dr. Miguel Angel Vaca Franco.

REFERENCES

Received on November 18, 2004.

Revised on November 23, 2004.

Accepted on February 17, 2005.

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Publication Dates

• Publication in this collection
  15 Sept 2005
• Date of issue
  Apr 2005

History

• Accepted
  17 Feb 2005
• Reviewed
  23 Nov 2004
• Received
  18 Nov 2004