Applying the Principle of Locus, Focus and Modus in Medical Education: Adapting to Enhance Clinical Management Strategies in Psychiatry

Dear Editor, It is often observed in academic rounds that formulating a treatment plan is difficult for psychiatric residents, especially among 1st-year residents. There is a lack of textbooks or published literature on how to present the best systematic management plan for patient care in academic presentation. I learned about the principle of “locus”, “focus”, and “modus” for formulating a management plan for our patient care during my residency from 2002 to 2004.[1] While researching these principles of locus, focus, and modus, I found that Clifford Dwight Waldo, an American political scientist articulated these concepts in the field of public administration. I also discovered that these principles are often used in business models. I believe these principles of locus, focus, and modus provide the best systematic clinical management plan in academic medicine, particularly in psychiatry. Therefore, the author aims to briefly discuss the adaptation of these principles in case presentations in academic psychiatry for the benefit of medical students and residents. Residents are expected to present their management plan for their case after presenting the history taking and examination findings, as well as case summary and case formulation,[2] along with at least a provisional diagnosis of the case. Table 1 gives a brief on these concepts.Table 1: Concept and description of the clinical management planLocus deals with the “where” aspect of clinical care for patients and refers to the best setting/place to treat a particular patient. This could be either outpatient, inpatient, emergency, or referral to another department. Residents must logically build a reason for choosing the setting, in which the patient can be treated best. In general, inpatient care is advised for diagnostic clarification, nonresponders to previous treatment, if psychiatric disorders are severe either by the presence of symptoms or by imminent symptoms such as suicidal/homicidal risk and comorbidity. Please note that, in India, residents need to keep in mind about the provisions of Mental Healthcare Act 2017 for inpatient care. Outpatient care is advised for mild-to-moderate severity of psychiatric disorders without any risk or comorbidity and is expected to improve in the anticipated way. Emergency care is advised for patients who have suicidal or homicidal risk, side effects, or to rule out organicity for psychiatric signs and symptoms, etc. Referral care is advised to other clinical departments based on symptom profiles and examination findings. Focus deals with the “what” aspects of clinical care for patients. Target symptoms should be defined at the beginning of patient care, as this will help focus and monitor the progress of improvement or worsening of the patient’s condition. For example, suicidal risk and depressive symptoms can be targeted symptoms for inpatient care, panic attacks in outpatient care, or aggression in emergency care. Modus deals with the “how” aspects of clinical care for patients. In psychiatry, the author advises using the clarify, assess, and treat (CAT) approach to formulate the modus aspect of the patient care plan. The CAT approach stands for clarifying history gaps, assessment (psychiatric, psychological, social and physical), and treatment (pharmacotherapy and non-pharmacological treatment include psychological and social management). Clarifying history gaps involves addressing any omissions in the patient’s history, such as often-missed premorbid personality (PMP) or sexual history, which may be skipped in a hurry. The assessment aspect of the CAT approach includes psychiatric, psychological, social, and physical assessments. At this stage, wherever required, the need to referral/liaison with other specialties and multidisciplinary teams can be considered. The psychiatric assessment includes a serial mental status examination (MSE) to monitor the progress of symptoms and to address unanswered questions from the baseline MSE. This also involves the use of rating scales and diagnostic instruments such as Structured Clinical Interview for DSM (Diagnostic and Statistical Manual of Mental Disorders) or International Personality Disorder Examination. Routine use of rating scales is advisable for all trainees, as it fine-tunes clinical skills in psychiatry and provides an objective measure of the severity of the patient’s disease. It is best to administer the most common rating scale specific to the patient’s diagnosis. For example, Young Mania Rating Scale for mania, Hamilton Depression Rating Scale for depression, etc. For a general assessment of severity and improvement, Clinical Global Impression-Severity and Clinical Global Impression-Improvement as well as the Sheehan Disability Scale may be used. Psychological assessment include intelligence quotient (IQ) assessment including clinically relevant 1 min IQ test for grading of IQ,[3] diagnostic psychometry, psychotherapy assessment, etc. In physical assessment (medical investigations), only the relevant laboratory tests and imaging studies should be considered. The reasons for these relevant investigations should be noted. In the treatment aspect of the CAT approach, pharmacological, psychological, and social management plans should be formulated. The author advises the following timelines: immediate (up to a week), short-term (up to 1 month), medium-term (up to 6 months), and long-term (more than 6 months). This approach is crucial in cases such as emergencies, where only an immediate plan can be made initially. In inpatient care, presenting an immediate plan and waiting for early responses and investigation report(s) are advisable. Although a full range of plans may seem ideal, personalized management is essential as plans may change with new information and treatment responses. Trainees should practice formulating immediate-, short-, medium-, and long-term plans in daily clinical learning, but only present an immediate plan during examinations due to the dynamic nature of long-term plans. In pharmacological management, it is always advisable to specify the exact name of the medication(s) along with its dosage schedule and the rationale for this choice. It is vague to mention only the classification of the medication; instead, name your specific choice within the classification. For example, state, “I will begin with olanzapine 5 mg and slowly increase to 20 mg,” instead of simply saying “atypical antipsychotic.” Remember, the efficacy of a group of medications in psychiatry is almost the same. Therefore, the rationale for choosing a particular medication in psychiatry mainly depends on side effects, affordability for the patient, availability, and the patient’s or their family’s history of response to that medication. At least one rationale for your choice of medication should be included. Similarly, the rationale for polypharmacy needs to build whenever planned. In psychological management, it is better to personalize or customize the psychological methods for the given patient. In psychological management, need to categorize various available resources into counseling, health education, and therapies. Author adapts the description of health education and counseling given in telemedicine guidelines of India for psychiatry as follows.[4] In psychiatric care, health education involves a trainee and practicing psychiatrists providing guidance to promote mental well-being and prevent psychiatric disorders. This may include advice on stress management, coping strategies, healthy sleep habits, and the importance of regular physical activity for mental health. In addition, the professional may offer information on medication adherence, the impact of substance use on mental health, and the importance of a supportive environment. In psychiatry, counseling involves offering patients personalized guidance to support their mental health and well-being. This may include recommendations for managing medication side effects, strategies for coping with anxiety or depression, tips for maintaining a healthy sleep routine, and advice on the proper use of therapeutic tools such as mindfulness techniques. In addition, counseling may involve discussing the need for further psychological assessments or tests that should be completed before the next appointment. Types of therapies, for example, use cognitive behavioral therapy (CBT) for cognitive errors in major depressive disorder, and CBT for cognitive errors in obsessive–compulsive disorder, social phobia, generalized anxiety disorder, etc. In social management, consider providing a leave certificate, disability certificate, and contacting school authorities for child school refusal, etc. Involving the spouse and family members in the treatment of the patient is of paramount importance, especially in cases of severe mental disorders. Remember, treatment is incomplete without educating patients and their families. The author preferred to use the term “education” instead of “psychoeducation” in this paper in view of stigma of prefix ‘psycho’.[5] The rehabilitation and reintegration plan of the patient into society could be in medium-or long-term plan. To conclude, formulating treatment plans is challenging for psychiatric residents, especially 1st-years. The principles of locus, focus, and modus offer a systematic approach in academic psychiatry. Locus identifies the best treatment setting, focus defines target symptoms, and modus outlines the methodology using the CAT approach. Assessments should be comprehensive and personalized. Treatment plans must specify medications, doses, and rationales, and include immediate-, short-, medium-, and long-term goals, with an emphasis on immediate plans during examinations. Family involvement and education are crucial in social management plans. These principles help residents create effective, personalized management plans that adapt to patients’ evolving needs. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.