Psychiatric training in Russia: challenges and perspectives Alexey Pavlichenko, MD, PhD Moscow State University Russian Society Of Medicine and Dentistry of Psychiatrists 1

Comparison of “psychiatric myths” among medical students and population in Russia Psychiatric mythsFirst-year students Final-year students Population People become psychiatric patients by chance 36%31%33% Mental illness is a result of lack of will20%13%72% Hex may result in any mental disorder20%16%32% Mental disorders are recompenses for one’s sins 24%20%17% Mental disorders are communicable12%11%13% - Medical students’ opinions of psychiatry reflect the prevailing views in society rather than training in the specialty Ruzhenkov V., Moskvitina U. Rus. Psychiatr. J. 2010; 4:

Differences between training curricula on paper and in practice in Europe - There are significant differences in content and quality of training curricula across Europe -In only 7 countries (24%) the curriculum was in line with training conditions in practice -The most problematic issues of curriculum: psychotherapy, research and addictions -The most common difficulties in the implementation of the psychiatric curriculum: lack of time; lack of appropriate rewards for trainers; lack of quality control measure; a shortage of supervisors -Quality control measures in the most countries are absent or consist of formal questionnaires Kuzman M. et al. World Psychiatry. 2012; 2:135 3

Medical education in Russia Undergraduate higher education (6 years) including psychiatric training (144 hours) Postgraduate education CompulsoryExtended Clinical residency (the so-called ordinatura): 2 year Residencyship (the so-called internatura): 1 year Retrainer course: 500 hours Refresher course: 1 time per 5 years: 144 h. Postgraduate studies (the so-called aspirantura): 3 years (PhD program) Doctoral studies (the so-called doctorantura): 5 years (Doctor of Science) 4

Levels of psychiatric training -First level Medical school: course in psychiatry during fourth year of training – 3 weeks (144 h.) -Second level Residencyship (the so-called internatura) – 1 year (1728 h.) Clinical residency (the so-called ordinatura)- 2 years (3456 h.) - Third level (Research) Postgraduate studies (the so-called aspirantura): 3 years (PhD) Doctoral studies (the so-called doctorantura): 5 years (Dr.Sci.) 5

Challenges of psychiatric training at medical school - Gap between content and quality of training curricula and modern knowledge in psychiatry -Insufficient duration of training (144 hours) -Difficulties to provide training conditions in psychotherapy, addiction and child psychiatry -Teaching of psychiatry before other clinical disciplines - Methods of assessment of knowledge is associated with memorizing rather than understanding underlying theories 6

Teaching on psychiatric clinic -Formal ward rounds (examine the patients, bedside manner, “tricky” cases) -Attending other hospital departments including addiction’s, children’s, eating disorders’ ones -Psychiatric interview: ask students to write down their observations and discuss with a clinician afterwards -Encourage self-directed learning: student’s clinical case report, allow see “tricky” cases on their own, making presentation Adapted from El-Sayeh et al. Adv. Psychiatr.treat. 2006; 12:

Additional forms of teaching -Attending scientific conferences and congresses -Duty at the admission department together with clinicians -Working in a psychiatric hospital as a medical staff -Using modern technologies: teleconferences, webinars, E-learning (“virtual learning environment”) 8

Critical problems of teachers -“Self-stigmatization” of psychiatrists -Uncertainty of lecturer’ position (clinician, teacher or researcher?) -Low wages (two-three times less than the salary of adult psychiatrists ) -Lack of motivation to improve the qualification -“Burn out syndrome”: late for work, detachment, lack of motivation, decline in the quality of teaching 9

Perspectives of psychiatric training at medical school -Combine psychiatry and psychology into a single discipline -To focus on the psychosocial aspects of medicine and on non-pathological experience in the beginning of training -Offering students an experience in other psychiatric settings including inpatient and outpatient services -Methods of assessment of knowledge should be focused on understanding rather than memorizing -To attract new technologies including E-learning 10

Challenges of postgraduate education Methodological -Lack of quality control measures -Disintegration of educational institution - A general shortage of supervisors -Lack of uniform standards of training curricula -A shortage of teaching materials Social and economic - Reduction of state-funded places -Low material and technical recourses -Low wages for trainers and supervisors -Low motivation to conti- nuous medical education - Inappropriate clinical settings 11

Supervision NOW -One supervisor is responsible for 5-10 trainees - Lack of individual approach -Only one theoretical practice per two weeks -Control measures: Pass/fail grading test -1 year Certification exam – 2 year POSSIBLE VARIANT - Weekly individual practice during 1 hour -Not more than 4 trainees per a supervisor -Control measures: Formal (training curricula, exam, trainees’ diary) Informal (privately, academic background) Robertson J Adv. Psychiatr.treat

Professional Examination NOW -Computerized test (out of date) -Oral interview with a professor (quite a subjective opinion) POSSIBLE VARIANT -Updated computerized test in line with modern knowledge in psychiatry -Oral interview including solution of clinical descriptions. Formalized criteria of assessment are required - A certificate of Continuous medical education 13

Continuous Medical Education - Full-time/distance learning: lectures, webinars, teleconferences, thematic improvement, forum -Attending Scientific Conferences and Congresses -Participating in case conferences -Self-directed learning: self-education, research, publications 14

Challenges of postgraduate studies -Absence of standardized training curricula for future researchers -Low technical resources (fMRI, medications) -Low quality of PhD thesis in psychiatry -Most of psychiatric research does not meet the principles of evidence based medicine -Absence of demand for future researchers 15

Perspectives of postgraduate education -Harmonization of training curricula with the Directives of the European Union of Medical Specialties (UEMS) -Increasing of duration of psychiatric training up to 3 (4) years -Reforming of postgraduate studies’ institutions (the so called “aspirantura” and “doctorantura”) -Improvement of training conditions in practice (material and technical resources) -Implementation of Continuous medical education’s system 16

The role of Russian Society of Psychiatrists in psychiatric training NOW -The section on Education of RSP -The traditional school for ECPs each 2 years -Educational module for specialists at the RSP’ website FUTURE -Create of continuous medical education’s system -Sign up the agreement to WPA granted credits for CME activities -Provide mutual recognition of psychiatric certificates -Motivate to continuing education (grants, scholarship) 17

Training in psychiatry in the EU and Russia: similarities and differences Similarities 1.Theoretical training (except for such issue as research methodology and leadership) 2.Training in biological psychiatry 3. Training of old age psychiatry 4.Supervision in psychiatry 5.Quality assurance in specialist training in psychiatry Differences 1. Training in psychotherapy (incl. individual supervision) 2. Training in community psychiatry 3. Lack of training in forensic psychiatry, addictive disorders and sexual disorders (subspecialities in Russia) 18

Psychiatric training in Russia: perspectives Compulsory postgraduate education clinical residency in psychiatry (3 years and more)+ additional training in subspecialties (psychotherapy, narcology) Continuous Medical Education training and self-education Medical College clinical psychology, psychiatry, pharmacology, neurology, physiology, anatomy, pathology 19

Conclusions -Views of future doctors on psychiatry and mentally ill people are wrong -Insufficient duration of training, outdated training curricula and absence of CME are the main challenges of psychiatric education in Russia -Postgraduates studies (PhD program) should be reformed -The role of Russian Society of Psychiatrists should be increased at all levels of psychiatric training 20