International Review of Psychiatry, August 2010; 22(4): 378381

Addressing psychiatric education in Latin America: Challenges and opportunities

RODOLFO FAHRER1, MIGUEL R. JORGE2, & PEDRO RUIZ3
Department of Psychiatry, University of Buenos Aires and Department of Psychiatry, Foundation for Clinical and Research in Neurosciences (FLENI), Buenos Aires, Argentina, 2Department of Psychiatry, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil, and 3Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, Florida, USA
1

Abstract This article is about the psychiatric educational components in the field of psychiatry. Currently the training and educational objectives focus on five major areas: undergraduate education (medical students); graduate education (psychiatric residents); psychiatric education for primary care physicians, as well as physicians in other medical specializations (psychosomatic training); public health and public education at large, and patient and family education, and the promotion of mental health at a community level. Given the strong globalization process observed in all regions of the world in the past two or three decades, it is very important for Latin America to constantly review and update its psychiatric and behavioural sciences curriculum across all medical institutions and universities of the continent. New methods of teaching and novel approaches to education in the field of psychiatry are currently based on models that are also in use in other parts of the world, especially in the USA. Boards of certification for psychiatrists are being implemented all over the continent. Sound certification guarantees that the professional has followed and passed an educational training plan to make him/her qualified to start practising the profession. The future of psychiatric training will be closely bound to the future of the practice of psychiatry, and will have to get ahead of the challenges the specialism will face during the next decades.

Introduction With a population of over 600 million inhabitants, who are primarily concentrated in urban areas throughout the continent, Latin America currently has about 20,000 psychiatrists. Latin America is a fertile region for the assimilation and adaptation of the rich clinical, psychopathological, therapeutic, institutional, and operational educational contributions that have been initiated or have influenced Latin America during the last several centuries. The field of psychiatry in Latin America has been enriched over the years with the growth and contributions in such areas as psychoanalysis and psychodynamic psychotherapy, psychotherapy at large, psychopharmacology, social and community psychiatry, neurobiology and neurosciences, evidence-based clinical practice, as well as a marked emphasis on ethical and socioeconomic related factors. Additionally, during the last two decades, a strong humanistic influence has also permeated the field of psychiatry in this continent (Ruiz, 2005).

Psychiatric educational components The teaching and educational components within the field of psychiatry were officially introduced into the curriculum of most medical schools throughout Latin America at the end of the nineteenth century. Examples of this were clearly observed in Mexico, Argentina and Brazil. The pioneering educational work concentrated in the field of psychiatry with strong focus in psychiatric training in Latin America dates back to the third decade of the twentieth century (Alarcon, 1990). However, education and training in the field of psychiatry and behavioural sciences is still a great challenge nowadays as it was in the past. It constitutes, however, an important and relevant role in all the medical education branches for both medical students and psychiatric residents (Ruiz, 1998). Currently, the training and educational objectives in the field of psychiatry and behavioural sciences focus on five major areas within that field. They are: 1. 2. Undergraduate education (medical students). Graduate education (psychiatric residents).

Correspondence: Dr Rodolfo Fahrer, Salguero 2436 (8th Floor), 1425 Buenos Aires, Argentina, South America. Tel: 0054 11 482 48452. Fax: 0054 11 482 48847. E-mail: fahrer@ciudad.com.ar ISSN 09540261 print/ISSN 13691627 online 2010 Institute of Psychiatry DOI: 10.3109/09540261.2010.501612

Addressing psychiatric education in Latin America 3. Psychiatric education for primary care physicians, as well as physicians in other medical specialists (psychosomatic training). Public health and public education at large insofar as psychiatric and mental health are concerned. Patient and family education, as well as promotion of mental health at a community level.

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Hodges et al., 2001; Patel, 2003). These types of training efforts directed to primary care professionals in Latin America and abroad include: . Brief lectures or presentation with audio-visual techniques. . Discussion groups using video techniques with strong focus on patient interviews. . New methods of intervention and skills development supported by audio-visual techniques. . Role-playing in small group settings. . Video feedback focusing on small group settings. New methods of teaching and novel approaches to education in the field of psychiatry are currently based on models that are also in use in other parts of the world, especially in the United States (Webb et al., 1996). In Latin America, the current graduate and postgraduate training in psychiatry encompasses exposure and learning exercises in settings such as emergency services, inpatient units, outpatient programmes, consultation and liaison programmes, sub-specialized training in areas such as child and adolescent psychiatry, geriatric psychiatry, forensic psychiatry, addiction psychiatry, administrative psychiatry, and research fellowships. Obviously, we do not have enough general psychiatrists in Latin America, but even fewer among the sub-specialist areas within psychiatry. Hopefully, new opportunities in these areas will be initiated and developed in the near future. Basic training for general psychiatrists also includes neurology and medicine/primary care. The primary care strategy is believed to be the fastest and most effective way to reduce the social gap in health status that currently exists in Latin America (PAHO, 2007). This strategy calls for the gradual, systematic, and organized decentralization of health and mental health services throughout the continent. This strategy also anticipates for local government to implement health and mental health policies directed not only to the appropriate psychiatric and mental health care of the population in Latin America, but to the development of mental health preventive initiatives as well. Obviously, the psychiatric training in Latin America must include humanistic, ethical, scientific and technological aspects. Additionally, these factors must all be well integrated into the training and education of medical students, psychiatric residents and fellows, and also the primary care professional sectors as well. In Mexico, in the year 1972, and following the model of the American Board of Psychiatry and Neurology from the USA, as well as the experience of the Royal College of Psychiatrists in the UK, the Mexican Board of Psychiatry was founded by the initiative of the Mexican Psychiatric Association and

4.

5.

The psychiatric and behavioural training and education of medical students at the undergraduate level has recently received great attention and priority, not only in Latin America, but all over the world as well (WPA, 1996). Obviously, it is very important for medical students to learn about psychiatry and behavioural sciences, for instance about knowledge, attitudes and skills at a time that they are receptive to new ideas and expertise. At the medical student level, this type of training is important because the relevance of the integration of the mindbody concept; additionally, the knowledge of psychiatry and behavioural sciences is essential to all branches of medicine, and nowadays the role of psychosomatic knowledge and expertise is extremely relevant in the field of medicine at large. The World Psychiatric Association (WPA) undergraduate curriculum in psychiatry offers unique approaches to the clinical problems and challenges in the psychiatry and behavioural sciences fields across the world. These special and unique characteristics in the field of psychiatry and behavioural sciences around the world lead the current attention given to the practice of both medicine and psychiatry in different regions of the world; this is essential nowadays given the strong globalization process that has been clearly observed in all regions of the world in the last two or three decades (WPA, 2002). For all of these previously addressed reasons it is very important for Latin America to constantly review and update its psychiatric and behavioural sciences curriculum across all medical institutions and universities of the continent. This ongoing growth in the areas of psychiatric training and ` education will also have a positive impact vis-a-vis stigma, disparities and discrimination, all of which are still quite frequently observed in the field of psychiatry, not only in Latin America, but in North America and other regions of the world as well (Ruiz, 2000). With respect to graduate and post-graduate education and training, much interest and attention has been recently given not only in Latin America, but worldwide as well (WPA, 2002). Likewise, the psychiatric training among primary care professionals has also received much attention all over Latin America in recent years, as well as across the world (Gask, Baron, & Fahrer, 2005;

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R. Fahrer et al. Assessment of knowledge is tested by means of written tests with multiple choice options (questions on psychiatry and neurology), and the assessment of skills and abilities is performed by means of the examination of a psychiatric patient to review the doctorpatient relationship, the sensitivity of the professional, the empathy, the skill to establish rapport, the skill to obtain the patients cooperation, observations skills, etc. The professional must arrive at a diagnosis with differential diagnosis, prognosis and treatment. The assessment checks on how he manages the patient therapeutically from the biological, psychological, social and rehabilitation points of view, are also conducted. In Brazil, voluntary certification for psychiatrists is a joint task conducted by the Brazilian Medical Association (AMB) and the Brazilian Association of Psychiatry (ABP) since 1973. Physicians that have successfully completed an official three-year medical residency training programme or can prove to have five years of experience in psychiatry can apply to be a board certified general psychiatrist, and then be fully tested in order to get certification. If he or she is already board certified as a general psychiatrist, it is also possible to apply for a certification in a subspecialism within psychiatry: forensic, child and adolescent, or geriatric psychiatry. A five-year recertification process for different medical specialisms including psychiatry was adopted by the Federal Council of Medicine, the Brazilian Medical Association, and its medical specialist societies (such as the Brazilian Association of Psychiatry) since 2006 through the National Accreditation Committee that gives credit for different types of continuous medical education activities (scientific meetings, courses, publications, presentations, academic titles, etc.). Similar boards are being implemented all over the continent. Nowadays, the general view is that psychiatrists must be recertified and the services where they work and train must be accredited. Sound certification guarantees that the professional has followed and passed an educational training plan that makes him/her qualified to start practising the profession. Recertification ensures that the specialists, legally responsible for their actions, have the proper training that allows them to demonstrate their ability to effectively deliver medical services in their specialism. This refers to professional maturity and implies personal experience. Recertification must be periodical because the advances in medicine are changing all the time and the psychophysical state of the professional might be altered for different reasons. We have to differentiate between clinical and theoretical recertification. Both certification as well as recertification have to be performed by peers.

with the participation of the Mexican Society of Biological Psychiatry, and under the sponsorship of the National Academy of Medicine. The specialists who are responsible the requirements established by this Board regarding knowledge and expertise in the specialism of psychiatry are thus certified with the objective of maintaining professional standards in the care of the community. It is not a compulsory policy, but it is voluntary. In 1994, the foundations were laid for the recertification in psychiatry as a way of checking whether specialists have continued with their updating process which allows them to have the necessary knowledge for the adequate exercise of the frequent and important contributions in a specialism where advances are significant and constant, and where it is very easy to become uninformed. This is not a new evaluation; this is an evaluation of the continued education of the professionals having participated in courses, workshops, seminars, sessions, participation in national and international congresses, teaching activities and non-supervised continued education, journals, reading, etc. Once these requisites are met by means of a score system during five years, another evaluation is taken and the professionals are credited and recertified (Vasquez, 1999). In Argentina, in the year 1999 and under the sponsorship of the National Academy of Medicine as well as the Board of Certification of Professional Physicians, the consensus on the process of certification in psychiatry in the Argentine Republic took place; this culminated in a Workshop-Seminar in which, besides the above mentioned institutions, there were representatives from the United States, Mexico, Israel, the World Psychiatric Association, the Argentine Medical Association, the universities from all over Argentina, the associations of professional psychiatrists, and with the sponsorship of governmental institutions and the Pan American Health Organization. The Board of Certification for Medical Psychiatrists was thus founded, and this includes medical psychiatrists certified by the Board of Certification of Professional Physicians and the Psychiatric Educational Commission. In the year 2000 an important document was issued focusing on the requirements for certification in psychiatry throughout the system of residencies (Consejo de Certification de Profesionales Medicos, 2002). To apply for certification, the professional must be accredited, be a matriculated physician, having completed an educational postgraduate programme allowing him to fulfil the necessary expertise to meet the requested profile of the specialism (medical residencies or equivalent alternative programmes), and be interested in voluntarily applying for certification.

Addressing psychiatric education in Latin America The educational potential in hospitals and mental health centres can be attested by the quality of the professionals leaving the residencies which have to be improved and optimized. The challenge is that education is not only produced in fomal settings, but that there exist other places with great educational potential to be profited in order to connect the theoretical elements of formal education with practical clinical realities. The trend is to extract the maximum educational potential from all health institutions (Montenegro & Mella, 2003). The future of psychiatric training will be closely bound to the future of the practice of psychiatry, but it will have to get ahead of the challenges the specialism will have to face during the next decades. As one of our leading South American psychiatrists said we can affirm that the current Latin American psychiatry is hybrid, social and critical. It accepts the common thematic core with the rest of world psychiatry, but it locates it and looks its pathoplastic expression in our historical and cultural context. Thus it needs to express its identity to promote or restore health in a Latin American population with its own diverse and different problems, with a peculiar symbolic register of the illness before which the psychiatrists commitment goes way beyond what is strictly professional to achieve ethical and authentically existential levels (Alarcon, 1995). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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