Acad Psychiatry (2014) 38:55–57 DOI 10.1007/s40596-013-0009-3
IN DEPTH ARTICLE: COMMENTARY
DSM-5: A Teachable Moment Richard F. Summers & Timothy R. Kreider
Received: 4 November 2013 / Accepted: 5 November 2013 / Published online: 14 January 2014 # Academic Psychiatry 2014
Abstract The rollout of DSM-5 is both a challenge and an opportunity for psychiatrists and particularly for trainees. Psychiatric education in the wake of DSM-5 will go beyond memorizing lists of new criteria. Teachers and learners alike will seize the “teachable moment” to learn new content, model how to approach and apply new understanding, think about how new knowledge is developed, and appreciate the importance of public dialogue.We can capitalize on this moment to improve the teaching of assessment skills as a central focus of residency training. Keywords DSM-5 . Residency . Education . Assessment
DSM-5 and Psychiatric Assessment Psychiatric assessment is a central focus of residency education, and the advent of DSM-5 provides an unparalleled opportunity to improve training in this skill. The particular diagnostic labels and criteria change from DSM-IV to DSM-5, in some cases slightly and in others dramatically. More profound, however, is the potential for the manual’s new organization and emphasis to influence how we practice, teach, and think about assessment. Assessment skills—including gathering data, conceptualizing patients’ problems, and communicating with colleagues about clinical matters—are central to our profession. The content and organization of our diagnostic manual influence our clinical assessments, and the newness of DSM-5 gives assessment a new salience. This cluster of articles [1–5] is based on a combined APAAADPRT symposium presented at the 2013 APA annual meeting, with panelists representing a spectrum of perspectives from resident to DSM-5 Task Force Chair. We provide an overview of the impact of DSM-5 on residency training and a summary of the panel’s recommendations to psychiatric educators on how to respond to the opportunity offered by the rollout of DSM-5. R. F. Summers (*) : T. R. Kreider University of Pennsylvania, Philadelphia, PA, USA e-mail:
[email protected]
Major Changes in DSM-5 Whereas much of the public interest in DSM-5 focuses on tweaked criteria and new diagnoses, more influential on the practice of psychiatric assessment are changes in organization and emphasis. For example, the multiaxial system of diagnosis has been removed, reflecting the continued integration of psychiatry into biological medicine and eliminating distinctions between disorders that are historically based rather than clinically meaningful. Some diagnoses have been lumped, such as Asperger’s disorder or Schizophrenia, paranoid type; other diagnoses have been split apart into separate chapters, such as depressive and bipolar disorders and anxiety disorder, obsessive-compulsive disorder, and trauma- and stressorrelated disorders. Notable areas of increased emphasis in DSM-5 include developmental course, cultural differences, gender-related issues, and functional impairment of illness. There is renewed attention to psychosocial stressors and lifespan problems. Information on genetics and biomarkers are present where available, with the hope that more will follow as science progresses. The structure of the manual facilitates engagement of trainees in discussions about the interacting biological, psychological, and social factors of psychiatric illness, and its organization will inspire discussions about similarities and differences between various psychiatric disorders. Just as important as the content and structure of DSM-5 is the process of its creation and future evolution. The DSM-5 committees integrated clinical experience, scientific evidence, social consequences, and public concerns to an unprecedented degree in their consideration of proposed changes. The new manual is envisioned as a “living document” rather than authoritative “bible” and was designed with the expectation that basic research findings—inspired by programs like the NIMH RDoC and President Obama’s BRAIN Initiative—will be incorporated into smaller and more frequent updates (e.g., DSM-5.1). The diagnostic manual will grow and develop along with our scientific understanding and users of the manual will be part of a continuous learning process.
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Teaching Assessment The changes in the new DSM will inspire changes in clinical practice, particularly in the realm of assessment. Skills in conducting an interview and crafting a formulation are central to psychiatric education; they are the initial tasks for the early trainee and prerequisites for further tasks, such as treatment planning. Trainees practice their assessment skills in a variety of locations, including the emergency department, the psychiatric inpatient service, the medical unit, and the clinic office. No matter the context, however, the structure of a psychiatric interview is tied intimately to the data that must be gathered for the differential diagnosis, which in turn is determined by our diagnostic manual. Assessment will, thus, be affected by new criteria, new emphasis on development and culture, elimination of the multiaxial system, addition of measurement scales, and other changes in DSM-5. More specifically, DSM-5 represents a major step in the direction of dimensional (as opposed to categorical) diagnosis. Diagnostic specifiers are provided liberally to encourage clinicians to indicate both the quality and quantity of symptoms present. This enhanced flexibility is designed to allow for greater precision and to reduce reliance on “Not Otherwise Specified” diagnoses. Section III of DSM-5 introduces quantitative measures: cross-cutting and domain-specific symptom scales that can be used to grade and track a patient’s severity of illness. Additional dimensional tools include an alternative trait-based model for personality disorders and The World Health Organization Disability Assessment Schedule 2.0 for describing functional impairment. In the course of learning such tools, trainees will be reminded that selecting the best diagnostic label is only part of a comprehensive assessment. Patient assessment is based on the clinician’s understanding of psychiatric illness, and the reorganization of the diagnostic manual promotes a re-conceptualization of some illnesses. For example, the way a trainee thinks about bipolar or obsessive-compulsive disorders will shift now that those disorders are no longer included in the mood and anxiety disorders chapters and are seen as more distinct. Given that this restructuring is based on emerging scientific evidence (such as the genetic overlap between schizophrenia and bipolar type 1 disorder), today’s trainees learning assessment with DSM-5 will be better positioned to integrate future discoveries into their understanding of psychiatric diagnosis. These new ideas may promote a new generation of clinicians who think differently. Challenges and Opportunities Implementing DSM-5 requires psychiatric educators to address the trainee curriculum, their own continuing education, adoption and training by other department faculty, changes in medical record and billing systems, and public controversy.
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The first challenge for educators and trainees is to learn a new text that represents an evolution from the previous version. However, this task will be complicated in its timing for current students and residents, because DSM-5 arrives just when they were learning DSM-IV. Trainees will feel the pressure to master both editions in parallel due to the lag in its full incorporation into the ABPN, PRITE and USMLE examinations. The transition could confuse students and risk the impression that psychiatry is less rigorous than other medical specialties. A solution is to teach the DSM as a document with historical context and an evolving future. Changes to criteria will be easier to learn when they are explained with reference to the incremental scientific knowledge that informed the change. Stories about how psychiatrists and neuroscientists arrived at our current understanding of mental illness are compelling, and such illustrations will be a welcome addition to dry lists of symptoms. Furthermore, the manual is an opportunity to teach and learn about how scientific discovery contributes to clinical psychiatry. Education about the process of creating new knowledge may include detailed discussion of research methodologies and technologies, perhaps inspiring residents to join in the effort. An emphasis on context, process, and relevance will help educators teach the content. Trainees are not the only ones who will need to learn the new text, of course. The switch to DSM-5 may be threatening to clinicians long-familiar with the previous edition. The changes of DSM-5 are both broad and immediate, different from the gradual pace of scientific advancement that typically drives faculty development and continuing medical education. The coordinators of Grand Rounds must include sessions dedicated to the major revisions and also incorporate relevant new criteria into other sessions during the transition. Master educators in the department may be recruited to lead in-service events to ensure that faculty members are prepared to teach trainees and use DSM-5 in clinical skills assessments. Furthermore, academic departments will be a resource for community and privatepractice psychiatrists, as well as for physicians and colleagues in other specialties. Educators and other faculty will have the opportunity to model curious and dedicated lifelong learning. Trainees must learn content and technique, but they must also learn how to improve their knowledge base and skill set continually after leaving residency. Senior clinicians will teach trainees by demonstrating how they themselves learn new material. Scientific evidence and consensus are evolving processes, and therefore expertise is a moving target. A new DSM reminds all psychiatrists not to become stagnant or comfortable but rather to remain committed to lifelong learning and ongoing practice improvement. A necessary practical step will be training in the impact of the DSM-5 on billing and coding. This training will help residents
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learn about the financial and administrative aspects of the health care system. Finally, although we may wish to focus on the content and structure of DSM-5, public controversy is unavoidable in psychiatry. Responses to DSM-5 have ranged from celebratory to condemnatory, from careful critiques to preemptive panning, and trainees will encounter criticism of DSM-5 in their everyday and clinical lives. Rather than avoid hard questions, educators should prepare students to engage in discussions about the manual’s strengths and limitations. The public interest in DSM-5 is a wonderful opportunity to help trainees think critically about the methodological, technological, and philosophical aspects of psychiatric diagnosis. Recommendations The panelists in the symposium made a wide variety of excellent recommendations, which we condense and summarize below. Please read the papers that follow (1-5) for a more thorough discussion of these educational approaches. &
Mobilize and coordinate didactics to teach new criteria, and reinforce didactics in bedside teaching, Grand Rounds, and other clinical teaching settings.
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Model lifelong learning through faculty learning alongside trainees. Teach the scientific methods and results that informed the creation of DSM-5. Tell stories about the historical context for past and present nosologic systems. Incorporate DSM-5 organization and Section III quantitative measures into clinical practice. Emphasize clinical assessment of stressors, resiliency, and level of functioning. Clearly delineate for residents when each type of exam will begin testing DSM-5 criteria. Discuss the impact of DSM-5 on billing, coding, documentation, and patient psychoeducation. Promote consideration of the patient as person along with consideration of diagnosis and formulation. Review and assess departmental clinical settings and their role in teaching psychiatric assessment. Provide feedback to departmental leadership about the relevance and effectiveness of clinical services. Improve “Teaching the Teachers” training and mentoring for residents as they approach their role as teachers of more junior residents and medical students.
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Conclusion The rollout of DSM-5 is both a challenge and an opportunity for psychiatrists and particularly for trainees. Psychiatric education in the wake of DSM-5 will go beyond memorizing lists of new criteria. Teachers and learners alike will seize the “teachable moment” to learn new content, model how to approach and apply new understanding, think about how new knowledge is developed, and appreciate the importance of public dialogue. We can capitalize on this moment to improve the teaching of assessment skills as a central focus of residency training. Like any scientific advance, DSM-5 should be presented to trainees as a “next step” rather than a pinnacle of knowledge. An ultimate goal of psychiatric education is to enable trainees to be self-motivated lifelong learners in anticipation of future DSM updates and scientific developments, and faculty will serve as role models of this process of self-improvement. Current trainees and educators should view the advent of DSM-5 as a welcome opportunity and meet the inevitable challenges with curiosity, wisdom, and optimism. Implications for Educators & Renew focus on assessment skills & Teach the scientific methods and results that informed the creation of DSM-5 and the meaningful controversies surrounding its use & Model continuing education and lifelong learning
Implications for Academic Leaders & Review departmental clinical settings and their role in psychiatric education and learning about psychiatric assessment & Support faculty learning about DSM-5 & Incorporate DSM-5 organization and Section III quantitative measures into clinical practice
References 1. Kupfer D. DSM-5: New opportunities and challenges for teaching and training. Acad Psychiatry. 2013. doi: 10.1007/s40596-013-0002-x. 2. Roberts LW. DSM-5 and the five missions shouldered by chairs of psychiatry. Acad Psychiatry. 2013. doi: 10.1007/s40596-013-0010-x. 3. Dingle A. The DSM-5: An opportunity to affirm “The Whole Child” concept in child and adolescent psychiatric residency training. Acad Psychiatry. 2013. doi: 10.1007/s40596-013-0007-5. 4. Benjamin S. DSM-5 to-do list for adult psychiatry residency directors. Acad Psychiatry. 2013. doi: 10.1007/s40596-013-0008-4. 5. D’Souza N. Transition to DSM-5: the resident perspective. Acad Psychiatry. 2013. doi: 10.1007/s40596-013-0004-8.