Primarycare_chapter6

Neuropsychiatric� Education

Introduction :

�� A responsible medical school or medical education system should have the means of ensuring the students graduate , or obtain a license to practice medicine , only if they have acquired the necessary skills and abilities . This in fact is the purpose of a final qualifying examination , i.e. to safeguard the legitimate interests of society by certifying that a graduate is fit to practice (Costa E Silva J.A. , 1991) .

�� To master the art of medical discipline , the student has to pass through the following six well known phases of education and learning : Premedical , preclinical� , medical , graduate , postgraduate and finally continuing education with possibility of further training or subspecialisation .��

�� In a survey to which medical students who participated in a preclinical preceptorship and their preceptors responded. Whereas 73% of the students reported being interested in primary care, only 43% of the preceptors agreed that the students were considering primary care careers (Hale F.A. ,Abyad A. 1993).

Principles of� Neuropsychiatric Teaching

�� Teaching neuropsychiatric skills appears to be a great challenge to medical teaching allover the world . The challenge comes from the fact that although two sciences are integrated together , and there is a large comorbidity between them , each one of them needs a different method of approach .

�� The integration between the two comes from the biological link between both groups , thus teaching both sciences should be established in a coordinated form , making simpler approaches to disease diagnosis and treatment and not empashizing on etiology nor complicated methods of investigations which would be a an interest to a specialist� rather than the general practitioner .

Problem of Teaching in Egypt

�� In Egypt the education of neuropsychiatry was always judged through the specialist point of view (Okasha ,1995) . The curriculum of Neurology and psychiatry is taught in the last years of medical undergraduate teaching .

�� A main bias in teaching is the dependence on Central and university� Hospitals which usually attracts a variant of cases different than that the General practitioner is likely to see during his field practice . the use of rather expensive and sophisticated methods of treatments which are not usually available (Okasha A. ,1993).

�� In the following pages an attempt is made to identify� a rather integrated program of teaching for the Undergraduate and post graduate teaching . The Psychiatric curriculum would be placed on the Tenth International classification of disease the primary Health Care version with emphasis� on technical issues that is needed to be highlighted . The Neurology� program would differ than the formal method in categorizing the neurological disorders according to the prevalence and the urgency for intervention .

Objectives of Educational program

�� Both programs where placed to fulfill the main objectives� placed by the World health organization (WHO , 1980) . i. e. :

1 - To prevent or to reduce psychiatric , neurological and psychosocial problems , including those related to alcohol and drug dependence .

2 - To increase the effectiveness of general health services thorough appropriate utilization of medical health skills and knowledge .

3 - To develop local strategies for intervention

I - Psychiatry

Introduction :

�� In a review of psychological skills in general practice (Weinman and Medlik ,1985) empasizhed that developing skills in the detection of psychological problems is a fundamental area , and treatment cannot begin to be discussed if� general practitioners could not identify target patients .

�� over the past three decades a series of efforts have been made on an international plane to help the general worker to become more knowledgeable and skilled in dealing with mental health problems . Studies conducted in developing countries have revealed serious deficiencies in the teaching of psychiatry in medical schools , up to that some medical schools in developing countries do not include the behavioral sciences in their curriculum all ( Girgis S., 1970 ) .

�� The proper training of General practitioner would markedly reflex the management of patients . Williams & Balestrieri (1989) Found that in the parts of the UK where there was a greater increase in general practice-based psychiatry , there was also a greater decline in admissions of nonpsychotic patients .

�� On evaluation a university-based psychiatry curriculum for primary care through reviewing Physician interviews and chart audits , 79% of patients were unrecognized by Primary care physicians. Primary care physicians assumed that patients were functioning well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of patients. These patients generally received a diagnosis of adjustment disorder in response to medical treatment. ( Jones L.R., Badger L.W., Ficken R.P., Leeper J. D. , et-al� ,1988).

Principles of Psychiatric Education :

�� The most essential elements which contribute to any initiative aimed at developing an adequate national capacity for psychiatric training� ( Blackwood G.W. , Alexander D.A. , 1983) can be summarized in the following points :

1- Establishment of professional units or departments of psychiatry in under graduate medical schools .

2- Development of an integrative approach� incorporating general medical training and pediatric , public health and social medicine .

3- Psychology should be taught at the preclincal level in close linkage with the biological sciences .

4- Special attention should be paid to clinical psychiatry and case demonstration in outpatient settings , inpatient units in general hospitals , old custodial and isolated psychiatric hospitals can prove counter productive in training .

5- Medical students should be attached to a psychiatric teaching unit for a period of clinical clerkship .

6- The teaching program must be systematically evaluated . This should entail the inclusion of psychiatry in medical examinations and feedback from students to take psychiatry in a more serious way .

The current position in Egypt :

�� The study of psychiatry in Egypt is still affected by the clinical and experience of professional psychiatrist . In concern of the fact that out of 20 Egyptian medical student� only one will became entangled in the field of Neuropsychiatry and therefore psychiatric disorders such as Anxiety , Depressive and somatization disorders are to be focused upon as these are the most like Disorders to� be examined by General Practitioners (Okasha , 1994).Within this frame work Egypt is now adapting The WHO PHC version of ICD-10 . It is to be discussed in more details later .

�� It is Proposed that psychiatrists must use methods that entail active participation by general practitioners , use a taxonomy that is appropriate to the kinds of psychological illnesses seen by general practitioners , and be aware of the importance of somatic presentations of neurotic illness, in order to become effective teachers in primary care settings. Examples are given of 3 teaching methods (preliminary teaching , improving detection skills, and problem-based interviewing) that use TV equipment and promote active participation by general practitioners . Effective teaching must occur at the point of delivery of service and should focus on the doctor-patient encounter (Goldberg D. , 1986).

�� One of the most important aspects to be taught to a medical students is teaching them�� communication skills . Out of 60 departments of medical schools in the UK surveyed during the academic year 1989-1990 , 44 of them were involved in teaching communication skills. Departments of psychiatry and general practice played a major part .Although� there was wide variation in educational objectives and in the curricular time available the main Concern of the departments is expressed in establishing a good methods of communication between the doctor and the patient ( Whitehouse� C.R. ,1991).

�

World Health Organization Primary Care Project

�� In� 1993 the material of ICD-10 Primary health Care was distributed on a number of regional centers (including Egypt ) aiming to improve the quality of services delivered� by Primary Care Physicians .The core of the system included a 24 flipcard system of the most common psychiatric problems encountered in the primary care setting .Figure (1.6) includes a list of those . each diagnosis is approached in a multiple approaches trying to cover all aspects meeting with the primary health physician needs . Those approaches are listed in Figure (2.6) .

�

Category

ICD-10 Code

�� F00*

Dementia

�� F05

Delirium

�� F10

Alcohol Use Disorder

�� F11*

Drug Use Disorder

�� F17.1

Tobacco Use

�� F20*

Chronic Psychotic Disorders

�� F23.*

Acute Psychotic Disorders

�� F31

Bipolar Disorder

�� F32*

Depression

10-

�� F40*

Phobic Disorders

11-

�� F41.0

Panic Disorder

12-

�� F41.1

Generalized Anxiety

13-

�� F41.2

Mixed Anxiety & Depression

14-

�� F43*

Adjustment Disorder

15-

�� F44*

Dissociative Disorder (Conversion Hysteria)

16-

�� F45

Unexplained Somatic Symptoms

17-

�� F48.0

Neurasthenia

18-

�� F50*

eating Disorders

19-

�� F51*

Sleep Problems

20-

�� F52

Sexual disorders

21-

�� F70

Mental Retardation

22-

�� F90

Hyperkinetic �(Attention Deficit ) Disorder

23-

�� F91

Conduct Disorder

24-

�� F98.0

Enuresis

�(*) : Indicates that the category includes more than one of ICD-10 Codes

Figure (1.6) ICD-10 PHC� list of Categories

Presenting Complaints

Diagnostic Features

Differential Diagnosis

Essential Information For patient and family

Specific Counseling For patient and family

Medication

Specialist Counseling

Figure (2.6) Items included in each Flipcard

�� The material of ICD-10 Primary health Care can form a core for a system , not only to the primary health care . But the subjects and material could be expanded to form a course of undergraduate teaching .

�� It appears that the qualification of the general practitioner should start as early as preclinical level . The basic psychological knowledge and the clinical psychiatric evaluation tought in the final medical years could be the most important factor in detection of conscpious psychiatric morbidity . The mangemnt of psychitric conditions listed above at the primary care would elvate a major burden on the other levels of care and help for better medical service for the majority of population .

II - Neurology

� �� Major problem in medical education of Neurology today� is the lack of integration between basic sciences and clinical information into a cohesive whole . If either of these is taught in a vacuum , the medical students frequently is unable to reason through clinical problems and this can� result in anxiety , dislike� and eventual disinterest in the subject material .

�� Students perceive that the neural sciences and clinical neurology are overly complex , and many of these students develop a up to what can be termed� "Neuroophobia". Neurophobia can be defined as a fear of the neural sciences and clinical neurology that is due to the students inability to apply their knowledge of basic science to clinical situations�

( Jozefowicz R.F., 1995) .

�� It is suggested That Neurology Units handling undergraduate treatment should adopt a program who would introduce the Neurology as integrated part of the curriculum for medical students aiming to improve their skills in identifying and treating Neurological Disorders (Eltribi ,1995).� The classical method of teaching needs to� replaced by a simpler one that depends more on clinical approach to a common disorders (Jozefowicz R.F., 1995) .

�� The aims held for such a curriculum are to prepare The General practitioner to diagnose and mange simple Neurological cases , deal efficiently with acute neurological conditions , training for proper referral to other Care facilities . Figure (3.6) shows different Levels of Neurological problems encountered in general health settings demonstrates examples of cases correlating with these objectives . Figure (4.6) Shows briefly the main points most of the neurologists agree to be as� a basic skill in a general practitioner .

�� Neurology should be taught as one unit , the student must learn that with all points of history and examination should be fulfilled , Vogel (1992) performed an interesting study to show the value of different parts of case presentation .Routine neurological examination on 200 patients who were reexamined by a second physician under three different conditions:

(1) re-examination of only one item .

(2) complete reexamination without knowledge of the patient's history and complaints .

(3) complete reexamination with such knowledge .

It was found that� additional information increased reliability, indicating that diagnostic hypotheses obtained mainly from the history improve the examiner's precision. When a complete reexamination was performed with knowledge of the patient's history, reliability was substantial (kappa > 0.6). it is found that more experienced examiners do not perform the examination more reliably, but do utilize the patient's history differently.

Simple Neurological Problems

Bells palsy

(Cases that do not need high neurological skills to diagnose and Manage)

Trigeminal Neuralgia

Tension Headache

Migraine

Febrile Convulsions

Epilepsy (Idiopathic Generalized)

Acute Neurological Emergencies

Increased Intracranial Tension

(Cases that is either life threatening or crippling the patient , they will require specialist attention as soon as possible , The role of General Practitioner is to secure the patient life and capabilities till referral to a specialist is conducted

Status Epilepticus

Acute Stroke

�� & Stroke in Evolution

Mysthenic Crisis

Transverse Myelitis

Acute post Traumatic Spinal cord Lesion

Complicated Neurological Problems

Under diagnosed cases

(Cases which require a specialist team work and an expensive an sophisticated techniques e.g. Electopyhsiological ,neuro-radiology , Neuro-Histopathological techniques to reach a suitable diagnosis Here The role of GP is to Refer the patient with at least a suitable report to the attached specialized Center

�� Muscle Diseases

�� Peripheral nerves

�� Slow infections

Bedridden Patients

�� Paraplegia

�� Hemiplegia

�� Ataxia

Figure (3.6) Different Levels of Neurological problems Encountered in General Health Settings (Eltribi , 1995)

Phase I :

�

Applied Neuroanatomy

Basic

Applied Neurophysiology

�� Neurological

Case Taking

�� sciences

History Taking

Neurological Examination

Phase II :

Common

Cranial Nerves

�� Neurological

Headache

�� Disorders

Increased Intracranial Tension

Migraine & other types of Headache

Epilepsy

Intracranial tumors

Cerbrovascular accidents

(especially Risk factors and management)

Paraplegia

Phase III :

Neurological

Ataxia

�disorders

Muscle disease

� requiring a

Extra pyramidal Disorders

�� specialist team

Peripheral Nerve Lesion

Demylinting Disease

Myasthenia gravies

Phase IV :

Management�

Therapeutics in Neurology

Rehabilitation In Neurology

* Adopted by the author's permission

Figure (4.6) A curriculum for Medical students and General practitioners aiming to provide Basic Neurological skills (Eltribi, 1995)

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