Toward National Consensus on Psychiatry Internship Training

India with more than 700 medical colleges is among the countries training the largest number of doctors in the world, which will increase in coming years.[1] Interestingly, India has more than 200 million people affected with psychiatric conditions that need treatment as per the National Mental Health Survey 2015–2016. The treatment gap accounts for 85%, primarily because of the limited number of psychiatrists graduating which is <1300 per year, and minimal emphasis on psychiatry training at the undergraduate level. Every aspect related to medical undergraduate training becomes paramount for providing optimal psychiatry services in India. Competency-based medical education (CBME) was introduced in 2019 by the National Medical Commission (NMC), to enable skill development of graduating doctors in India. Psychiatry training in the new MBBS Curriculum was enhanced from 20 h of theory to 40 h. Two weeks of bedside clinics were increased to 6 weeks. Two weeks of internship is now made mandatory. Although there is a lot of clarity on what should be taught and how undergraduates should be trained in psychiatry CBME, particularly in theory and bedside clinic, there has been little discussion on psychiatry internship training.[2] Internship training is the crucial aspect of undergraduate training, where emerging doctors are trained in real-world scenarios at outpatient and inpatient services related to Psychiatry, there is an urgent need to have a consensus on what should be incorporated into Psychiatry internship training. The 2024 CBME guidelines related to Psychiatry have incorporated two certifiable skills, namely identification of depression and its management at primary care, and suicide risk assessment. There are now 17 competencies covering 13 topics in psychiatry. The topics are: (1) Classification of psychiatric disorders, history taking, and mental status examination (MSE). (2) Delerium and Dementia, (3) Substance use disorders, (4) Schizophrenia, (5) Depression (6) Mania (7) Anxiety Disorder, (8) Acute Stress and Adjustment Disorder, (9) Psychosexual disorders, (10) ADHD and Autism spectrum disorder, (11) Intellectual disability disorder, (12) Suicide risk assessment, (13) Modified Electroconvulsive Therapy. There have been efforts to look at Entrustable Professional Activities for internship. It might be possible for the Psychiatry fraternity across India to deliberate on what is the minimal requirement of internship training. Indian Psychiatric Society and the Indian Teachers of Psychiatry forum have joined hands to come out with a consensus on Psychiatry history taking, MSE, and Diagnostic formulation.[3] This greatly helps to improve the standard of training. Similar efforts are required to reach a consensus on psychiatry internships. Undoubtedly, emerging doctors should know how to approach patients presenting with depression and its management in primary care. They are also expected to understand how to identify and diagnose severe mental illnesses such as psychotic disorders (for example: schizophrenia). In the 2 weeks, it might be possible for an undergraduate to be trained in the identification and management of common substance use disorders such as nicotine dependence and alcohol dependence which is a major concern to the Indian context. It may also be possible for the internship training to look at how undergraduates can elicit and manage common anxiety disorders such as phobia and panic disorder. In some institutions, if the common conditions presented to the psychiatry department are related to legal aspects or disability-related certification requirements, the department can expose graduates to such important aspects of psychiatry. In those departments where sleep medicine, sexual medicine, neuromodulation, and other services are available Interns can be trained in them. Apart from common mental health conditions and some severe mental health conditions, internships can also be used for training doctors in simple psychotherapy techniques such as BATHE which might be useful in all scenarios.[4] In those institutions where modified electroconvulsive therapy is carried out routinely, interns can be encouraged to assist in the procedure. Role plays and simulations can be used to enable skill development. In 15 days of internship posting, empathy, reflective listening, ethics, and communication skills should be encouraged. Brief research projects can be taken up during the internship period whenever such interest is expressed. The assessment of the internship can be recorded in the electronic logbook (e-logbook), wherever departments have initiated them. The e-logbook can record if the learner was regular to the posting. The department can record if the professional qualities of Indian medical graduates (IMG) as noted in the NMC document, are present. The subcategories of the conditions listed in psychiatry CBME, wherever 15 days postings allow Interns to interact with the patients, the supervising faculty can record the competency in the simple categories of unsatisfactory, satisfactory, and more than satisfactory. Postgraduates in psychiatry, if available, can play an important role in assisting the faculty in the training and assessment of Interns. Such exposure will also enhance the teaching skills of psychiatry postgraduates. This is also an important aspect of psychiatry postgraduate training in CBME as notified by NMC. Internship assessment can also be conducted by more qualitative parameters such as reflective writings. Reflective writing can be based on the Intern’s exposure to patients presenting with one or another condition. It can also be about cumulative learning at the end of 15 days. The record of assessment can be useful even when graduates apply for further studies in countries abroad and request the department for recommendation letters. Psychiatry internships, when carried out diligently by the IMG and skilfully trained by the department in every medical college, can positively improve the competency of doctors. It is thus important that medical colleges across India are sensitized to the crucial role of psychiatry internship for enabling every upcoming MBBS doctor to address huge morbidity related to mental illness in India.