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PAPER |
1 Department of Neurology, Atkinson Morley Wing, St George’s Hospital, London, UK
2 Argyll & Bute Hospital, Lochgilphead, Scotland
3 Mayday University Hospital, Thornton Heath, UK
Correspondence to:
Correspondence to:
Dr F Schon
Mayday University Hospital, London Road, Thornton Heath CR7 7YE, UK; frederick.schon{at}mayday.nhs.co.uk
Received 17 August 2005
In final revised form 8 March 2006
Accepted for publication 9 March 2006
 | ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective: To assess attitudes of neurologists and psychiatrists to closer links in general and to joint education in particular.
Methods: Postal questionnaire survey of trainees (SpRs) trainers (Members of Special Advisory Committees in Neurology and General and Old Age Psychiatry) and teachers (Undergraduate coordinators). Analysis based on 55 neurology and 50 psychiatry respondents.
Results: 5 general attitude questions on links showed most respondents "keen" on links and "unkeen" on current separation of disciplines. 15 topics possibly suitable for joint teaching were offered. 7 were rated between "keen" and very "keen" with maximum support for somatization, dementia, chronic pain and pharmacology. 7 were rated positively, only eating disorders was felt unsuitable. 6 options were offered for joint training opportunities. Trainees were keen on attending joint education, clinical and patient management sessions and outpatient clinics. Psychiatrists were even keener on links than neurologists with psychiatric SpRs significantly more in favour of certain items.
Conclusions: The survey found widespread support from trainees, trainers and teachers for closer links. Trainees were keen to attend joint clinically focussed sessions. Psychiatrists tended to be keener that neurologists on links. This survey should encourage the establishment of closer educational links at all levels.
Abbreviations: SAC, specialist advisory committee; SpR, specialist registrar
Currently, the practice of neurology and psychiatry in the UK is effectively completely separate. The critical reason for reassessing this issue is the explosion of knowledge in basic brain sciences, which underpin both disciplines. Many experts have argued in recent years that this new situation is effectively redefining both disciplines and perhaps, in particular, moving psychiatry closer to neurology.1–7
Neurology is currently mostly practised in hospitals with major links to general and acute medicine and psychiatry deals with mainly chronic disease, often in a community setting. These vast practical differences make it difficult to see how the specialties may come closer in the near future. One potential way of bridging this divide would be by linking undergraduate and postgraduate teaching and training, which are at present poles apart.
This study is a questionnaire-based survey looking at attitudes to educational and training links focusing separately on undergraduate teaching and postgraduate training. The three groups whose opinions were sought were
| METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Section 1 looked at general attitudes to links and was entitled "How do you feel about the following opinions?" The section consisted of five questions, each followed by five options ranging from strongly disagree to strongly agree.
Section 2 gave a list of common topics or diagnoses (13 in the undergraduate and 15 in the postgraduate version) potentially suitable for integrated teaching, and asked how much the respondent believed each subject lent itself to integrated teaching, again offering the same five options.
The questionnaire given to undergraduate coordinators contained a third section asking about current teaching arrangements for neurology and psychiatry in each medical school.
The questionnaires to SpRs and SACs contained a third section, which asked about attitudes towards six different types of joint potential teaching sessions or attachments: joint educational meetings, a formal 3-month attachment, outpatient clinics, clinical meetings on disease management (such as ward rounds), emergency on-call observation and hospital and community meetings on chronic patient management.
The final part asked the SpRs: "Would you personally wish to attend integrated teaching sessions?"
The SAC version asked two similar questions: "Would you personally wish to be involved in setting up integrated teaching sessions?" "Do you feel some integrated teaching sessions for both sets of registrars is a realistic ten year ambition?"
All three questionnaires ended with a section asking for general comments on education and links.
The undergraduate version was sent to the 26 UK medical schools, the SAC version to all 15 members of the Neurology Committee and the 16 members of the General and Old Age Psychiatry SAC and the SpR version to 80 registrars, 40 from each discipline.
Neurology trainees were selected from the Association of British Neurologists database and psychiatrists from the South Thames General and Old Age Psychiatry database.
The results were calculated by giving a score of 0–4 for each question, all of which offered five options, with 4 being the most positive response: 0, very unkeen; 1, unkeen; 2, neutral; 3, keen; 4, very keen.
Data were coded for group membership using Microsoft Excel V.2000. Independent sample t tests were examined for intergroup responses, and also between the overall divisions of neurology and psychiatry. Levene’s test was used to assess equality of variance. The statistical software used was SPSS V.12 for Microsoft Windows V.2000.
| RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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In all three groups, response rates from neurologists and psychiatrists were similar.
Undergraduate links
In the undergraduate survey, at least one reply was received from 22 of the 26 medical schools approached. The following seven schools already had close links in undergraduate teaching: Dundee, Edinburgh and Liverpool, and The Royal Free, St George’s, The Royal London and King’s, Guy’s and St Thomas’s Hospitals in London. These links usually included several weeks of neurology teaching, followed by a usually longer period of psychiatry teaching. With rare exceptions, there is currently no joint teaching when neurologists and psychiatrists run shared sessions. In Brighton, Hull and Manchester, there are some links in the curriculum, but the remaining 12 medical schools have few or no connections. Psychiatry showed close links to primary care in six medical schools, neurology to ophthalmology in six and to general medicine in three medical schools.
General attitude questions
Table 1
shows the mean response to the five general attitude questions, giving the results for all three groups surveyed and from both disciplines. More than 75% of those responding were personally for closer links (score 2.7–3.1), only 20% believed that the subjects should be kept separate (score 1.2–1.6) and 75% believed that integrated teaching was an important issue.
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This reached significance at p<0.05 for the SpRs for the first, third and fifth statements.
Topic teaching
Table 2 shows the support for integrated teaching on the 15 topics as total mean responses from all the three groups surveyed.
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The responses were not statistically different among the whole group, but psychiatrists were keener than neurologists on joint teaching for 12 of the 15 topics.
The SpR results, in contrast, were statistically different on five topics, with psychiatry trainees keener on joint teaching of epilepsy, head injury, multiple sclerosis, neuropharmacology and Parkinson’s disease (p<0.01–0.001).
Joint training opportunities
The SpRs and trainers were asked about support for six different potential joint training opportunities (table 3).
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Trainees were asked how keen they personally were to attend joint sessions and their scores disclosed great interest (table 4). Trainers were slightly less keen to participate in setting up joint sessions, but most thought it was a realistic 10-year ambition.
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Undergraduate coordinators pointed out the following general issues:
The following are some comments from individual undergraduate coordinators:
Some comments from individual SAC members are as follows:
A selection of comments from psychiatry SpRs is given below:
Selected comments from neurology SpRs are as follows:
| DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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The main conclusion common to all three groups and both disciplines is a widespread, high level of support and interest in teaching and training links. Support was equally strong among trainees who were unselected, as among educators who, by virtue of their positions, were selected for their interest in education and training.
The results are in agreement with those expressed in recent years by many leading experts in basic neuroscience,1–4 as well as clinical neurology and psychiatry.4–6 Their importance, however, may lie in the fact that they are perhaps the first to show how widespread these ideas are at the grassroots level.
The need for both disciplines to redefine themselves in the light of advances in brain science has been emphasised by the Nobel prize winner Eric Kandell1–3 and Vilayamir S Ramachandran,4 the BBC Reith lecturer for 2003, who took a rather one-sided view when he said, "The boundary between neurology and psychiatry is becoming increasingly blurred and it’s only a matter of time before psychiatry becomes just another branch of neurology".
The central role that redesigned education programmes in both neurology and psychiatry should have in this process has been particularly advocated by the Harvard Medical School. Price et al6 in 1999 entitled their essay "Neurology and psychiatry—closing the great divide". A similar plea was made in 2002 in a BMJ editorial7 entitled "The wall between neurology and psychiatry—advances in neuroscience indicate it is time to tear it down".
The second finding was that, although neurologists were keen, they tended to be less keen on links than psychiatrists. This is perhaps surprising, as the importance of psychiatry to everyday neurological practice was recently emphasised when it was shown that as many as one third of new outpatient attendees have so-called medically unexplained symptoms.8 The need for neurology as well as psychiatry to change was pointed out by Stone and Sharpe9 when they wrote "Will a greater understanding of neuroscience mean that psychiatry will simply follow neurology in abandoning the patients that fail to fit into a reductionist paradigm?"
The desirability of neurologists forging wider links, including those with psychogeriatrics in management of dementia, is central to the 2003 document of the Association of British Neurologists,10UK neurology—the next ten years. Likewise, the importance of neurology being seen as more "user friendly" by non-neurologists and medical students has also been advocated.11,12
The justification for establishing educational links is to improve patient care. We believe that bringing the two disciplines closer will extend the spectrum of knowledge and skills of both specialties: neurologists can gain greater expertise in many aspects of chronic, community-based care as well as in "soft" syndromes (medically unexplained symptoms), and psychiatrists in the diagnosis, investigation and management of patients with relevant brain disorders. The gap between diseases of the mind and the brain is narrowing all the time. Recent papers have used neuroimaging to look at the effects of psychotherapy, and one group showed changes in hippocampal volumes during treatment for post-traumatic stress disorder.13,14
A reappraisal is needed, starting at undergraduate level, through junior doctor training and now also through consultant continuing medical education, reflecting the narrowing of the gap between mind and brain diseases, which in reality is an outdated concept. Each medical school should increasingly link the teaching of basic neuroscience, psychiatry, neurology and psychology.
Currently, senior house officers and SpRs in both neurology and psychiatry are being taught the major overlap topics, such as dementia, somatisation, pharmacology, head injury, chronic pain and others, in total isolation, by different "ologists", in different places and at different times, although often in the same institutions.
These results strongly suggest that trainees and trainers are open to a more integrated approach. One potential development is the establishment of a basic clinical neuroscience training programme as part of the new foundation years. This would enable junior doctors considering specialising in neurology, neurosurgery, psychiatry, rehabilitation medicine and elderly care medicine to attend a neurology attachment before starting specialist training. Another approach would be to establish joint training days for both sets of SpRs in each discipline, covering topics of mutual relevance.
In conclusion, we hope that these results will embolden those overseeing postgraduate training (the Royal Colleges of Medicine and Psychiatry, and the Postgraduate Medical Education and Training Board) to begin the process of bringing education in neurology and psychiatry closer.
| ACKNOWLEDGEMENTS |
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| FOOTNOTES |
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Competing interests: None declared.
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