Education In Psychiatry Research Paper

Medical education currently is the driving force in many sectors of professional administration in medicine. To cite a few examples: postgraduate Deans administer salaries of doctors in postgraduate training; physicians in training are posted only to academically accredited hospitals; and many countries require continuing medical education credits for doctors to hold hospital appointments.

The contemporary managerial revolution in health care and the medicine-for-profit ideology have imposed an unanticipated educational limitation. Since ancient Greece the vocation of Medicine has been hallowed as a calling; to foster learning has always been esteemed. Now even born teachers can have their investment in teaching curtailed by their institution, if their educational zeal is judged to intrude on the potential for generating income through clinical work.

1.1 Reform And Stasis

Efforts to reform medical school curricula commonly fail because, as medical education research demonstrates repeatedly, the institution omits to change the committee structure (governance) of the medical school to be congruent with new educational goals. A curriculum left in the hands of departmental heads inevitably remains static. A Curriculum Committee, given autonomy and its own resources such as budgets, answerable to the Dean and not to departments, is essential. Departments are then still free to pursue their specific noneducational goals, such as research and clinical work, to which in any case they give greater priority (Abrahamson 1996).

Medical education has long derived crucial research impetus from the social sciences. Pioneering sociologists, most fortunately for medicine, elected to study medical education (Merton et al. 1957) when they started investigating the professions to determine why professionals do not exploit their clients more than is the case. The classic New York study at Cornell, The Student-Physician, followed by the investigation of Kansas medical school by Chicago sociologists, led to the conspicuous leadership which (Becker et al. 1961) medicine has provided in higher education generally. Sociologists, by studying the medical school as a social organization (Bloom 1988), have also explored obstruction to educational innovation. The resistances to curricular change in medical schools derive from apathy on the part of some medical teachers; the necessary critical mass of teaching staff, educationally informed, interested, and involved in the education of medical students, is not achieved. Medical teachers, in common with their counterparts in the rest of academia, commonly assume they are equipped to teach simply by virtue of their expertise in their research or specialist discipline: they are ignorant of the medical education literature, and do not know or respect the findings of medical education research (Miller 1980). They have very often not had personal instruction about how to teach.

Medical students learn best, they repeatedly convey when surveyed, when active student participation is encouraged; when the emphasis is on applied problem-solving (rather than learning of factual materials); when instruction is student-centered; and when teachers are humanistically oriented.

The shibboleth that everybody must learn the same syllabus has proved amazingly resilient. Emphasis on memorization of fact, resulting in information overload, has been the age-old obstacle to active learning. Teaching and learning methods are being revolutionized by electronic information technologies, problem-based learning, and simulated (standardized) patients. Scope is being given for critical thinking, and the development of clinical competence made a priority. Time has been freed for special interest options of students. Educational leadership is essential, often not provided by Deans deflected by administrative priorities; and students have to be valued partners as change agents at every level, participating actively in monitoring the quality of their education.

1.2 The Applicant Pool And Selection

There is now considerable attention being given to widening the range of entrants to medical school, to avoid discrimination according to gender (male and female entrants are now equal numerically), ethnicity, social class, etc. Applying to enter medical school, given the great social desirability of the profession, is much documented and potential entrants are assiduously briefed and groomed (Iserson 1997).

Selection procedures have been investigated intensively. Entry criteria have centered on cognitive abilities unduly (e.g., school-leaving examination results), with nonintellectual attributes (e.g., motivation, empathy, humanism, drive, and determination) neglected. Once admitted, the student in a good medical school is responsibly respected and fostered (Merton et al. 1957, Coombs 1998).

2. Basic Medical Education

Medical education must be viewed as a continuum, with three constituent components: (a) basic medical education; (b) specialist training; and, (c) continuing education to maintain professional competence throughout professional life.

The medical school curriculum is the preparation for ensuing specialist training. The medical school phase results in a generic doctor, who can enter further training appropriate to a particular specialty. No doctor, in de eloped countries, relies any longer on his or her medical school education as the basis for his or her professional competence: all doctors, general practitioners as well, enter specialist training.

2.1 Psychiatry In The Medical School Curriculum

Psychiatry is a specialty in the field of medicine. All psychiatrists, in the first place, are medical doctors. Education in psychiatry starts, therefore, with entry to medical school, and basic medical education provides the start of the professionalization process.

In psychiatry specifically, the World Federation for Medical Education and the World Psychiatric Association in partnership have planned and instituted The Core Curriculum in Psychiatry for Medical Students (1999), the first ever global specification in any specialty, of the knowledge, skills, and attitudes which every doctor worldwide needs to learn about that specialty while at medical school. The Core Curriculum in Psychiatry specifies the minimum psychiatric instruction required by all medical students before proceeding to further training as specialists or as general practitioners.

Teachers of Psychiatry must concern themselves with the total curriculum of the medical school, and be involved with the governance of the medical school, serving on the educational committees that plan and implement the overall curriculum. Psychiatrists in medical schools must concern themselves with, and contribute to, all the canonical components of medical education in general: access (application to medical school, selection procedures, dropout, and wastage); curriculum; teaching methods; educational objectives; assessment and examinations; and evaluation and accreditation. Moreover, the departmental teaching of psychiatry must accord with the general institutional objectives of the medical school.

All branches of medicine, psychiatry of course also, are urgently confronted by the necessity to reorient the curriculum, to ensure not only curative medicine is taught, but also prevention of illness and promotion of health. Because of the great variation existing among countries and different cultures, any description of the program for psychiatry is of necessity schematic, but general principles can be set out which will apply in any setting.

Psychiatry must have a major place in the basic medical curriculum. (a) Understanding body–mind interaction, the unity of the person, is pertinent to the whole of medical practice, constantly advanced by research in the neurosciences. (b) Skills that are learned in psychiatry (e.g., the ability to form a good relationship with a patient, to assess the mental state, and to impart distressing information) are important for all doctors. (c) Psychiatric illness is common among patients seen by specialists in the other branches of medicine: among general medical outpatients, for example, about 15 percent given a medical diagnosis also have an associated psychiatric disorder; up to 40 percent of those given no specific diagnosis in fact have a psychiatric disorder. Psychiatric disorders are even more frequent among patients seen in general practice (Clare and Lader 1982). (d) Psychiatrists treat only a small portion of any nation’s psychiatric morbidity; a great bulk of psychiatric disorder is managed, adequately or otherwise, by doctors whose psychiatric training often is confined to their exposure to psychiatry as medical students. All medical students require the psychiatry program, regardless of the branch of medicine they are destined to practice in the future.

2.2 Broad Goals In Teaching Psychiatry

When surveyed, teachers of psychiatry make clear the educational outcomes they consider the psychiatric program should achieve (Walton 1986).

(a) Psychological-mindedness. Communication skills and empathy with patients’ emotional responses, and capacity for the interpersonal relationship between clinician and patient—the basis of the medical interview.

(b) An objective approach to behavior. Behavioral science teaching (notably psychology and sociology) provides students with scientific knowledge about behavior, augmenting their common-sense understanding with empirical knowledge.

(c) Contact with psychiatric patients. Relating clinically to patients, with a wide range of psychiatric illness and disorder, permits students to dispel their own anxieties about mental patients, and to overcome the prejudices and preconceptions customary in their society; they need therefore to develop skills in history-taking, in examining the mental state, and in psychiatric interviewing of a patient repeatedly over a period of time.

(d) Descriptive psychiatry. Theoretical instruction about symptoms, signs, and syndromes, dealt with in the psychiatric textbooks, augments the clinical training when medical students are given proper access to patients.

(e) Treatment methods. A great proportion of all ill health being psychiatric, general practitioners and specialists in branches of medicine other than psychiatry inevitably deal with much the greater part of the mental health needs of the community. Knowledge about the main psychiatric treatment methods and skills is therefore essential for all future doctors.

2.3 Psychiatrists As Medical School Teachers

Psychiatrists have to overcome traditional disadvantages. Medical school teachers in general tend to view psychiatry as a backward branch of medicine. These nonpsychiatrist colleagues are further dismayed and confused by the doctrinal differences among psychiatrists (one a biologically oriented doctor favoring the medical model, the other a humanist concerned with psychodynamic processes, and practicing some or other form of psychotherapy). Medical school teachers in general are disconcerted when these contrasting ideologies come to be applied to the patients they refer to psychiatrists. It can sometimes seem relatively arbitrary how any patient will be diagnosed and treated—too much appears to depend on the outlook of the individual psychiatrist. Coterie positions are struck (see Coyle and Mollica of Harvard in Current Opinion in Psychiatry 1998, who have iconoclastically advocated that psychotherapy skills be ‘deferred’ to psychologists, social workers, counselors and clergy, whom they view as better suited for attending to the ‘local taxonomy of human suffering’).

Medical students acquire their professional values and outlook, in large measure, by modeling themselves on leading and respected teachers in the medical school. Investigations by sociologists, classically those of Merton(1957) at Cornell medical school in New York and Chuval (1980) in Israel have demonstrated that the status of psychiatry, of teachers of psychiatry, and of psychiatric patients in medical schools is not at the level of, say, medicine or surgery, with a seriously adverse effect on the teaching of psychiatry.

2.4 Medical Student Attitudes To Psychiatry

‘Psychologically minded’ medical students showed a greater interest in and a more positive attitude towards psychiatry than students scoring on tests as ‘organically oriented.’ Medical students’ preference for psychiatry as a future career is stable, the same before as after psychiatric instruction. Certain learning experiences, particularly the clinical clerkship in psychiatry when in particular types of unit, can change students’ attitudes towards psychiatry in a positive way. Only a very few percent of medical students choose psychiatry as a future career.

2.5 The Science Base Of Psychiatry

The sciences in the medical curriculum related to psychiatry include the biological sciences and the behavioral sciences. Science teaching in medicine has long been censured: a customary practice worldwide, instead of extending the ‘basic’ sciences throughout the curriculum, has been to compartmentalize the sciences in a so-called preclinical phase. Medical schools have imperatively to examine their entire educational program, in order to integrate science teaching properly with clinical instruction.

2.6 The Biological Sciences

Competing departmental interests fragment the sciences relevant to medicine into separate subjects (e.g., anatomy, physiology, pharmacology, etc.) at a time when integration of knowledge is the hallmark of advance (Eisenberg 1988). The new biology calls for an integrated view of whole structures, whether at molecular or macroscopic level. Medical schools have not responded sufficiently to the paradigm shift in science. Traditional basic science teaching in the medical schools stands charged with being outmoded, simplistic, and responsible for much of the information overload that mars medical curricula. Reform is a matter for the medical school as a whole, and is not to be left to the science disciplines in isolation from the clinical subjects.

2.7 Behavioral Science Teaching

Psychology and sociology in relation to medicine are viewed by departments of psychiatry as essential subjects in the curriculum. Despite this endorsement, behavioral sciences teaching remains problematic.

Medical teachers in general are skeptical about the ‘human sciences’ and not sympathetic to such issues as Kant’s fourth question: Was ist der Mensch?

Medical students and medical teachers alike are critical about the widespread failure in behavioral science teaching, given in the first or second year. Too often a condensed general psychology and sociology course is provided, which inevitably is perceived as lacking medical relevance. Equally misguided is to include behavioral science as an optional subject in an otherwise compulsory curriculum. Experience has shown that both clinically experienced medical (psychiatrists) and nonmedical (psychologists, sociologists) teachers must be actively involved in the planning and delivery of behavioral science courses, clinical cases included throughout, to avoid implications of irrelevance or discordance with students’ concerns as future doctors.

2.7.1 Psychology. Students should acquire a basic overall knowledge of the findings, methodologies, and theories of psychology which are relevant to the practice of medicine; be aware of how patients’ emotions, attitudes, values and experiences influence their response to illness and to its treatment; have a knowledge of learning processes and their relevance to medicine; possess knowledge about the main aspects of psychological development of humans from birth to old age; possess skills relevant to effective doctor–patient communication and particularly to interviewing; have knowledge of techniques of assessment used to test the reliability and validity of investigation procedures and therapeutic trials; and attain attitudes to development that will enable them as doctors to comprehend each patient as a complete person living in his or her own social environment.

2.7.2 Sociology. By the end of the course each student should understand: the various methods for defining and measuring health; know the importance for health and medical practice of social institutions such as the family, the community, the economy, and the law; understand the problems of equity and inequality in the provision and utilization of health services, related to age, gender, social class, and religion; grasp the changes in society and in the practice of medicine which have affected health and disease and the development of social policy; comprehend welfare provisions, the advantages and disadvantages of a country’s health service, and problems of planning for change within a health service; know about the social (and sociological) factors that influence the process of becoming ill and the doctor–patient relationship, and the effect that ill health and hospitalization have on the lives of patients and their families; be able to discuss critically the role of preventive medicine and health education, and the role of self-help groups; the process of medical professionalization; and describe some of the research methods used to evaluate health and medical practice.

2.7.3 Biostatistical Sciences. The aims of courses in the probabilistic and information sciences are: to explore ways of making valid deductions from medical data; familiarizing students with the basic statistical terminology as found in the medical literature; to introduce the concepts necessary for designing as well as analyzing comparison and experimental studies in medicine; and methods of accessing and/organizing medical knowledge; and computer literacy.

2.8 Clinical Psychiatry In The Curriculum

Instruction in clinical psychiatry must be integrated with the other main clinical subjects of the medical curriculum. The main teaching and learning methods in use are threefold: (a) lectures; (b) small group teaching; and (c) the clinical clerkship, a full-time attachment to a unit providing psychiatric care, in a general hospital psychiatric unit or in a psychiatric hospital, for six to eight weeks.

2.8.1 Objectives For Clinical Psychiatry In Medical School. The knowledge, skills, and attitudes to be achieved by the end of study (educational outcomes) are general, deal with organic and with functional syndromes, and with treatment and management:

(a) General. The student should be able to: conduct a diagnostic interview including a mental state examination; relate patients’ symptoms to their past experiences, personality, and social circumstances; give an account of his or her emotional responses to patients of different kinds and the way in which these reactions can influence judgment and hence the patient’s management; understand patients’ emotional responses to doctors and the way these can influence the presentation of illness; grasp the main principles of, and indications for, counseling and psychotherapeutic intervention.

(b) Organic psychiatry. The student should be able to: distinguish between organic and nonorganic psychiatric disturbance; recognize common organic mental disorders, including confusional states and dementia in different age groups; and management of organic syndromes in and out of hospital.

(c) Functional syndromes. The student should, for example, be able to describe: the management of depressive psychoses; schizophrenia and related psychoses; recognize common symptoms of neuroses; define and recognize the signs and symptoms of psychiatric illness; and the social services available for their management.

(d) Treatment methods and agencies. The student should be able to outline: the drugs commonly used; the principles of behavior modifications and their main clinical applications must be known; also important concepts in psychodynamic approaches, for example unconscious conflict and defense mechanisms; and the main agencies for the care and rehabilitation of the psychiatrically ill and those with learning disabilities in the community.

(e) Examinations. It is necessary to stress the importance of examinations, because examinations drive the curriculum. Students learn to pass examinations, whatever more high-minded educational emphasis teachers may seek to convey when specifying learning objectives. The assessment methods used should always be congruent with the objectives of the course. Only too often the methods of assessment are discordant. The professional examination needs to be composite: e.g., essay questions; short answer questions; an oral examination; continuous assessment during the clinical attachment, etc.

2.9 The Generic Medical Graduate

The product of basic medical education is a young doctor not yet equipped for independent practice on graduation. The goal of medical school is to produce a pluripotential doctor, who must then have postgraduate training to acquire the abilities needed for specialist (or generalist) practice. Prior to beginning such postgraduate training, the graduate is in the phase of transition from medical student to doctor.

The junior hospital doctor becomes a member of a consultant team in hospital. The notorious defects have been insufficient clinical supervision, insufficient feedback from consultants, excessive hours, and poor training standards with inadequate educational provision. Unless the general hospitals in which they work have psychiatry liaison services or psychiatric units, junior doctors receive no psychiatric instruction, and little incentive to consider training as a psychiatrist.

3. Specialist Training In Psychiatry

Training to become a specialist is the sector of medical education of particular significance to the specialty organization in each country (e.g., the American Medical Association, the American Psychiatric Association, etc.). General practice (family medicine), requires training that has a substantial psychiatry component, because of the epidemiological fact that the majority of psychiatric patients are seen not by specialist psychiatrists but by generalists.

Postgraduate training is in transition at present, not only nationally, but also worldwide. In part, this process of re-evaluation and reform results from the altering roles, responsibilities, and relationships of doctors, an upheaval so extensive and multifarious that the World Summit on Medical Education was designated: ‘The Changing Medical Profession’ (World Federation for Medical Education 1994).

Local context is crucial. Culture and history of each country are critically important in determining patterns of health care. Appropriately therefore each country continually reviews and reorients postgraduate medical education. Moreover, there are major differences between countries in their organizational frameworks for funding, delivering, and assessing postgraduate medical education. The professional nomenclature of psychiatric diseases and disorders varies: e.g., in North America the DSM-IV is used (American Psychiatric Association 2000) while in countries of Europe ICD-10 is the diagnostic system (World Health Organization 1992).

3.1 Structure And Implementation Of Specialist Training

Postgraduate training in almost all countries is the concern of the Ministry of Health, and takes place mainly in the hospitals of the country’s health service. Universities are associated with health services in the postgraduate training programs, e.g., twenty psychiatric hospitals in The Netherlands have psychiatric training approval, eight of which are university hospitals. Psychiatry is one of the medical specialties now undergoing profound change (Caldicott 1996).

Specialty organizations customarily set standards and hold examinations in postgraduate education. Their particular role differs considerably among countries. In the United Kingdom, taken as an example, the Royal Colleges and their Higher Training Committees have major responsibilities. Each College (including the Royal College of Psychiatrists) through its Higher Training Committee produces its own assessment standards. The Colleges set formal competitive examinations to regulate entry into higher specialist training. During specialist training in the UK the Higher Training Committee vets the quality of the training posts and the progress of each trainee specialist, through inspection visits and regular formative assessment of the trainee.

3.2 Clinical Training

Postgraduate training in psychiatry involves a sequence of posts, providing a wide range of clinical experience and making up a rotational training scheme, usually in one geographical area and often in one approved hospital complex. The rotational training scheme includes a university department or hospital, and allows experience in the various subspecialties of psychiatry, including in addition to adult general psychiatry: child and adolescent psychiatry, mental retardation, geriatric psychiatry, psychotherapy, general hospital (liaison) psychiatry, and other special fields.

3.3 Theoretical

The academic content of postgraduate training in psychiatry should include an introduction to general psychopathology, pharmacology, genetics, interviewing, diagnosis and classification, organic disorders, drug and alcohol dependence, schizophrenia, mood disorders, neurotic disorders, personality disorders, learning disability, psychiatric disorders of childhood and adolescence, old age psychiatry, forensic psychiatry, drug treatments, counseling and interpretative psychotherapies, behavioral and cognitive therapies, rehabilitation and community care.

3.4 Assessment Procedures

The specialist examination is taken at differing stages of training in different countries, and is also phased differently in the various specialties in each country. In order to sit the UK Royal College of Psychiatrists examination, trainees must have completed three years of psychiatric training and must be in a training post. After such general training, they may choose either to become general psychiatrists, or to enter additional training for a psychiatric subspecialty: e.g., in The Netherlands an additional two years in child psychiatry is required to obtain the Certificate of Completion of Specialist Training in Child Psychiatry.

In addition to the specialist examination, which as indicated above may be during the course of training, a number of countries have also introduced formal summative assessment at the end of specialist training. Equally important to trainees is feedback about performance, specific help about any weakness, and planning of future training.

3.5 Psychiatry Among The Medical Specialties

Countries differ in the separate specialties they identify. Psychiatry is not uniformly recognized, not even in all the countries in the European Union, regulated by law: the European Specialist Medical Qualifications Order, 1995. When psychiatry is one of the recognized specialties in a country, there are differences in training requirements including duration, e.g., it has been said that psychiatric training in the UK takes six to seven years, but four years in Portugal, Greece, or Belgium (with no formal examination in Belgium).

3.6 Subspecialties In Psychiatry

After general specialist training, young psychiatrists elect to undergo further training in subspecialties, and in professional life are designated according to the branch of the specialty in which they work. Adult psychiatry, child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, addiction psychiatry, etc. are differentiated, the range of categories varying to some extent in different countries.

3.7 National Differences In Standard Setting

In broad terms, five different patterns of responsibility for standard setting can be identified worldwide.

(a) National medical associations, as in Norway and Portugal, take the leading responsibility. In other words, the medical profession itself provides and dispenses the postgraduate training in the country. This is also the case in Germany, and in certain Central European countries.

(b) Designated professional bodies, distinct from the national medical association, may have major responsibilities, as in the United States where the specialty Board of Psychiatry, and in the United Kingdom where the Royal College of Psychiatry approve training posts as well as assess the competence of doctors in training.

(c) The government (Ministry of Health) together with the regional medical administration may take the main role. Sweden is an example of this arrangement. (d) Universities may be the chief responsible bodies, as in Finland and southern Europe.

(e) Postgraduate Institutes in some countries are, or were, the chief postgraduate authority, as in Central and Eastern Europe.

3.8 New Developments

In Europe, within each country, there has been steady evolution of postgraduate training over the past 20 years, with formal definition, recognition, and support given to the educational programs. International legislation controls important aspects of medical education in the European Union, in the interests of free inter-country movement of doctors among the member states.

So that women, in particular, are not penalized, training arrangements for doctors with domestic or other special responsibilities have to be specified, or parents who have interrupted their training for family reasons are precluded from re-entering medical practice. European Union directives on postgraduate medical education now also specify that the minimum number of hours of work in part-time training (for general practice, at least 60 percent of the hours worked by those employed full-time). Similarly, doctors training part-time in hospital specialties will be required to extend their already lengthy training on a pro-rata basis in order to qualify for specialist registration.

Postgraduate medical training has secured the confidence of the public in the medical care provided by accredited specialists. To cite the UK again simply as an example, the statutory basis for the medical education infrastructure has been long regarded as a major strength of the national system, the General Medical Council, the body responsible for the register of qualified medical practitioners, held in high repute. However, malpractice and legal infringements have recently undermined the long-standing confidence in self-regulation by the medical profession.

Doctors in postgraduate training have other professional needs which training programs must cater for. They require, for example, to learn the limits of their own competence, to identify and remedy deficits in their knowledge and skills, to learn when and how to seek the assistance of others, and to develop effective working relationships with professional colleagues and others. Structured training programs are therefore obligatory, which incorporate modern educational practice (Borman and O’Grady 1997).

4. Continuing Medical Education (Professional Development)

As a third great sector of medical education, maintenance of competence throughout professional life is now obligatory, and accepted as such by employing authorities, doctors themselves and the general public who require quality medical care and accountability by doctors for the clinical service they provide. Continuing medical education (CME), or professional development, consists of those educational activities undertaken by practicing doctors to maintain and update their clinical competence.

Medical journals and other medical scientific publications always were and continue to be paramount in disseminating new knowledge and promoting best clinical practice (Vysohlid and Walton 1990). Special continuing education courses were first introduced, in some middle European countries, for doctors practicing in state health services in 1878. As increasing numbers of countries introduced social insurance, furthermore, continuing improvement of their employees’ professional competence also came to be expected. This direct intervention and involvement of the state, to a lesser or greater extent, in promoting new knowledge and experience for doctors in the public health service is the original model of CME.

As pertains to all specialists, so also it is the personal responsibility of every psychiatrist to remain competent. This ultimate obligation of individual physicians calls for proper means to assess constantly the quality of their work and effectiveness of their professional services, such as a system of performance review. Agreed standards are necessary, and computerized medical records greatly enhance audit, the process of examining one’s clinical performance in relation to peers.

Being performance related, CME goes beyond information and knowledge, and focuses on the carrying out of actual clinical responsibility and services. The material included in CME, over and above lectures, case presentations, conferences, scientific meetings and conferring among clinical colleagues and their hospital firms or clinical teams, must be based on understanding of how adults learn: adults are oriented to tasks they undertake themselves, and to the personal interests they pursue. CME material must be relevant to the practitioner’s own daily responsibilities. Old-style courses, in which doctors were brought together to sit through series of lectures haphazardly given by outside experts, are not congruent. Mere attendance at CME courses for which credit is given cannot be assumed to improve professional competence.

There is widespread agreement that the CME system in a country must be closely integrated with the health care system, and related to the health needs of the population. Some countries are already imposing sanctions on doctors who do not engage in approved CME activities. Self-evidently, differences in the CME system between countries are to be expected and, indeed, greatly varying patterns are compounded by national realities in the health care services, the varying professional bodies with authority for medical education and training, and the forms of statutory regulation of the medical profession.

Since the Second World War, opportunity was provided for CME in practically all North American and European countries. CME is now always adapted to identified and actual needs of the health problems of the population, and to the health services, particularly in relation to primary health care and ambulatory settings. Coordination between medical school programs and subsequent specialty training programs has powerfully consolidated the provision for continuing medical education.

The provision of clinical information made available by modern information technology is the basis now needed for CME. Distance learning can combat the relative unavailability of CME for doctors working in rural areas and distant from the main teaching center.

All doctors have now to accept personal responsibility for maintaining professional competence throughout their working lives through CME. In addition, regular monitoring and revalidation are increasingly advocated. This third, and longest, phase of medical education is the most important, and both basic medical education and postgraduate training must now be planned and implemented as preparatory for lifelong CME, to ensure professional competence of all medical doctors throughout professional life. The imperative charge, on all nations, is for provision of effective medical services by sufficient, responsible, ethical doctors.

Bibliography:

1. Abrahamson S 1996 Essays on Medical Education. University Press of America, Lanham, MD
2. American Pychiatric Association 2000 Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Washington, DC
3. Becker H S, Geer H B, Hughes E C 1961 Boys in White: Student Culture in Medical School. University of Chicago Press, Chicago
4. Bloom S W 1988 Structure and ideology in medical education: an analysis of resistance to change. Journal of Health and Social Behavior 29: 294–306
5. Chuval J 1980 Entering Medicine: The Dynamics of Transition. Pergamon Press, Oxford, UK
6. Clare A W, Lader M (eds.) 1982 Psychiatry in General Practice. Academic Press, London
7. Coombs R H 1998 Surviving Medical School. Sage, New York
8. Coyle J T, Mollica R 1998 Psychiatry in medical education: a comment. Current Opinion in Psychiatry 11: 493–5
9. Eisenberg L 1988 Science in medicine: Too much or too little or too limited in scope? The American Journal of Medicine 84: 485–7
10. Flexner A 1910 Medical Education in the United States and Canada: a Report to the Carnegie Foundation for the Advancement of Teaching. Updyke, Boston
11. Iserson K V 1997 Get into Medical School: A Guide for the Perplexed. Galen Press, Tucson, AZ
12. Merton R K, Reader G, Kendall P 1957 The Student Physician. Columbia University Press, New York
13. Miller G 1980 Educating Medical Teachers. Harvard University Press, Cambridge, MA
14. Vysohlid J, Walton H J 1990 Development of continuing medical education in Europe: A review. Medical Education 24: 406–12
15. Walton H J (ed.) 1986 Education and Training in Psychiatry: A Case Study in the Continuity of Medical Education. Oxford University Press, London
16. Walton H J 1994 Continuing medical education in Europe: A survey. Medical Education 28: 333–42
17. World Federation for Medical Education 1988 The Edinburgh Declaration. Lancet 8608: 464
18. World Federation for Medical Education 1994 Proceedings of the world summit on medical education, 1993. Medical Education 28(1): 1–171
19. World Health Organization 1992 International Classification of Diseases, 10th edn. World Health Organization, Geneva, Switzerland
20. World Psychiatric Association and World Federation for Medical Education 1999 Core curriculum in psychiatry for medical students. Medical Education 33: 204–11