Promoting psychiatry in the medical school: the case of Uganda

Uganda has a rich history of medical education (Odonga, 1989) that was severely harmed by the rise of Idi Amin and the years of internal strife. It is only over recent years that the country has begun to rebuild itself (Boardman & Ovuga, 1997).

A central problem for psychiatry in Uganda is one of resources, compounded by high health needs and a relatively low priority given to mental health care. At present, there is only one psychiatrist per 2 million of the Ugandan population, which currently stands at 22 million and is growing at a rate of 2.7% per annum. Mental health practice is not economically rewarding; the discipline is shrouded in mystery and is highly stigmatised even among professional colleagues. Attracting graduates to specialise in psychiatry is painfully difficult and only 10 psychiatrists have graduated from the training programme since it was introduced.

Since 1992, the Department of Psychiatry has been experimenting with ways of creating and sustaining undergraduate student interest in the speciality. This paper describes the approaches used in the process of undergraduate medical education at Makerere University, Kampala, to promote psychiatry and to make it more attractive to students.

Undergraduate education

The first medical school in Uganda was set up in 1924 at Makerere University, Kampala (Odonga, 1989). Students in Uganda now undergo a 5-year undergraduate medical training. Makerere University Medical School admits 110-120 students per year. The undergraduate medical curriculum was revised in the mid-1980s and it became community-oriented in 1989. In 1989, sociology and psychology became examinable subjects on all undergraduate programmes in the faculty of medicine, including medicine, nursing, dentistry and pharmacy. With the introduction of the semester system throughout the university during the academic year 1996/1997, psychiatry and mental health became examinable subjects in medicine, dentistry, nursing and master of public health programmes.

Postgraduate education in psychiatry was introduced in 1969 and the first psychiatrist qualified in 1972. The Department of Psychiatry has 10 teaching posts, including three social workers, one medical sociologist and one clinical psychologist.

Undergraduate psychiatry

In 1992 the Department of Psychiatry introduced an innovative approach to the training of undergraduate medical and dental students in behavioural sciences during the first 2 years of their health sciences education. The aim was to provide an integrated knowledge of behavioural sciences, psychiatry, dental surgery and general medicine that would assist in preparing doctors for the integration of general health care and mental health services. We wished to promote the idea that psychiatric disorders should not be seen as alien and separate aspects of health care and to influence students to recognise the role of bio-psychosocial factors in illness causation and the management of health problems.

Psychology and sociology are taught in the first year, followed by an integrated course in applied psychology. The principles of social work and applied psychology are taught in the second year. Teaching takes the form of didactic lectures, interactive class discussions and practical assignments from the first term of the first year. At all times attempts are made to promote learning based on personal experience of health care provision and use. Students conduct practical sessions in small groups of 8-10 at a time. They interview patients or patients' attendants and each student writes his/her own findings and formulation of identified health and psychosocial problems based on interviews conducted. Each group elects one or two representatives to present the group's work to the whole class for discussion.

The psychiatric firm takes place during the fourth year of the medical curriculum and consists of 5 weeks of clerkships in psychiatry, during which time students are taught clinical skills in general and social psychiatry. Clerkships culminate in written and clinical examinations in general psychiatry and social psychiatry held at the end of semester. During the fifth year of the medical curriculum further clinical management skills are taught and examined.

This approach to medical education attempts to demonstrate the relevance of the integration of psychiatry in health care. The case work exercises in the third year are aimed at facilitating the acquisition of diagnostic and management skills during clinical rotation in psychiatry in the fourth year and the exercises in the fifth year at consolidating the knowledge so far acquired. Previously there were no psychiatric case work assignments in psychiatric education during the third and fifth years and this did not allow students to relate knowledge and concepts acquired during theoretical lectures to clinical practice in the fourth year clerkships.

Faculty Board

Over the years it had not been easy for the Faculty Board to accept innovations and suggestions for how best to teach psychiatry, let alone examine it separately from the discipline of internal medicine. The departmental leadership ensured active involvement of the department in all faculty curricula and administrative activities and functions. It has been vital for the faculty of medicine to appreciate that psychiatry is not solely concerned with ‘madness’ but with the promotion of overall health and of primary health care in Uganda. The consistent message that has been promoted is that comprehensive health care is not possible in the absence of mental health care skills among primary health care workers.

Discussion

The approach to psychiatric medical education at Makerere has not been aimed at creating mental health specialists, but directed to encourage students to appreciate that their future patients, who will seek health care principally for emotional problems, can be handled at the primary care centre just like any other clinical problem. This approach is consistent with the overall aims of the primary care mental health strategy (Ministry of Health, 1999a , b ) and in keeping with declarations to integrate medical education and the health care system (World Federation for Medical Education, 1994).

The place of behavioural sciences and psychiatry has been established in the medical curriculum and there has been a growing interest in these subjects among other faculties over successive years. Strong support for psychiatry comes from students: 15% of fifth year students indicated an interest in becoming psychiatrists and the provision of psychiatric and psychosocial services featured among the top five duties of the students as future health workers.

Psychiatry's success in medical education will depend on its ability to portray itself as a worthwhile discipline in which to train. The focus of psychiatric education in East Africa should be to equip undergraduate students with the skills and competencies to recognise, diagnose and manage common mental disorders and psychosocial disorders in primary care, and by doing so enable future doctors to perform the tasks of healing using the skills and concepts offered by psychiatry. In this context, psychiatry would appear to be the most appropriate speciality to teach counselling and communication skills, both of which are crucial in achieving optimal outcomes of clinical, preventive and health promotional services.

Psychiatry in Africa needs to explore ways in which to market itself as the only discipline that bridges the gap between biomedical and social science disciplines for health and economic development, something that will be familiar to psychiatrists in major capitalist nations. In the teaching of psychiatry at Makerere, mental illness has so far been portrayed to students as a natural human condition. Psychiatry is presented to students as an integral part of general health care, the concepts of which will facilitate the process of care giving in clinical practice.