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Postgraduate training for young psychiatrists—experience of the Berlin Summer School
European Psychiatry 21 (2006) 509–515 http://france.elsevier.com/direct/EURPSY/
Original article
Postgraduate training for young psychiatrists—experience of the Berlin Summer School A. Mihai a, A. Ströhle b,*, N. Maric c, A. Heinz b, H. Helmchen d, N. Sartorius e a
b
Department of Psychiatry, University of Medicine and Pharmacy, Tg. Mures, Romania Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité – University Medicine Berlin, Schumannstr. 20-21, 10117 Berlin, Germany c Institute of Psychiatry, Medical School, University of Belgrade, Clinical Center of Serbia, Belgrade, Serbia and Montenegro d Berlin-Brandenburg Academy of Science, Berlin, Germany e Chemin Colladon 14, 1209 Geneva, Switzerland Received 30 November 2004; accepted 17 May 2005 Available online 08 September 2005
Abstract Background. – Growing professional exchange between Eastern and Western European countries increases the possibilities for international postgraduate training courses and by that satisfying the need for rapid and facilitation of travel and migration in the enlarged European Union increase achieving high standards. The purpose of this study was to evaluate a summer school program that trained young Eastern European psychiatrists and to assess the impact of the program on their professional development and future activities. Method. – We evaluated the training effect of the first 3 years of the Berlin Summer School with respect to (1) the participants’ satisfaction with the topics, quality and originality of the presentations, and (2) long-term effects and implications for their professional career. All participants (N = 43) filled out anonymously the evaluation form at the end of each summer school. An evaluation of long-term effects was carried out 2 years later with a questionnaire that was sent via e-mail to all former participants. Results. – Participants were most satisfied with practical topics such as “how to prepare a paper”, “how to evaluate a paper”, or “how to participate in a congress.” The appreciation of the presented topics and the appreciation of courses increased in each consecutive summer school. All summer school participants reported that the course had some influence on their future career, and one fifth of the participants felt that their professional development was influenced “a lot”. Conclusions. – Although limited to 1 week of intensive training, a summer school program can have a longer lasting positive influence on the professional development of the participants. Participants felt that particularly the training of practical skills improved their research performance. Former participants founded an independent multicentric and multinational research group and supported national courses that were organized similar to the Berlin Summer School. © 2005 Elsevier Masson SAS. All rights reserved. Keywords: Postgraduate training; Psychiatric training; International networks
1. Introduction Developing professional skills is an important goal for trainees and young psychiatrists [10,11]. Young psychiatrists are usually well aware of limitations in their knowledge and professional skills, and understand the need for life-long learning [3,8]. In the recent literature, it has been supposed that trainees and trainers perceive a lack of training in non* Corresponding author. E-mail address: [email protected] (A. Ströhle). 0924-9338/$ - see front matter © 2005 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2005.05.001
clinical skills [5], which would be helpful for the growing professional exchange between Eastern and Western European countries. Facilitation of travel and migration in the enlarged European Union increase the chances for international postgraduate training courses [9] and by that support the need for rapid achieving high standards. In Europe, there is considerable variation in postgraduate training [6,2]. Therefore, international educational programs should keep in mind differences between European countries in terms of duration of residency, programs of education, but also with respect to the clinical and scientific experience and
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demands of young psychiatrists [4,12]. The most adequate development of (clinical and non-clinical) professional skills of European psychiatric trainees may be to organize multilevel courses, which are adapted to each target group and respect differences and previous experiences. Courses may be either international or national; in any case, they will profit from previous experience and exchange with ongoing efforts in postgraduate training (e.g. in old age psychiatry [1]). Here we describe an evaluation of the Berlin Summer School “Psychiatry as a Science” as an example of an international course organized on a multilevel basis and adapted to specific target groups. This Summer School has been educating Central and Eastern European young psychiatrists on a yearly base since 2000 and inspired similar schools and courses to be organized on a national level. The summer school started with several aims that have changed over time. At the beginning, a chief aim was to help in bringing together gifted and promising individuals from countries that came out of a terrible war. The orientation towards practical matters was a result of surveys on postgraduate training, descriptions of trainees and experience with the WPA program on professional skills for young psychiatrists. As a result the program combined practical instructions and review of current knowledge in key areas of psychiatry. Most of the course was organized in an interactive manner and the core faculty members were with the students throughout the time of the course. The purpose of this study was to evaluate the impact of training during the Berlin Summer School on the professional development and future activities of the participants. The effect of this training was evaluated with respect to (1) the participants immediately reported satisfaction with the topics and the quality and originality of the presentations, and (2) the long-term effects and implications for the professional career of the participants. In addition, we will present selected personal comments of participants and describe the Eastern European Psychiatric Scientific Initiative (E-EPSI) as an example for a network which was stimulated by the Berlin Summer School. The institutionalization of the Berlin Summer School and the establishment of national summer schools will be discussed. 2. Subjects, material and methods The Berlin Summer School “Psychiatry as a Science” is organized by the Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, in collaboration with the Berlin-Brandenburg Academy of Science. Introductory First level sessions were held in the summer of 2000 (First Berlin Summer School), 2001 (Second Berlin Summer School), and 2004 (Forth Berlin Summer School) and were based on the following educational objectives: • to impart professional skills (such as those involved in reading and presenting a scientific paper, designing and improving own research projects, publishing and presenting results of a study, coping with ethical problems etc.) and;
• to update knowledge in key areas of psychiatry (e.g. epidemiology, schizophrenia, affective disorders, addiction, anxiety disorders, sub-threshold disorders etc.). The topics were presented in highly interactive workshops with a great number of practices and individual tasks. The participants of both first level sessions of Berlin Summer School were 30 young psychiatrists from Central and Eastern European countries: Albania, Bulgaria, Bosnia, Czeck Republic, Croatia, Estonia, Hungary, Macedonia, Poland, Romania, Serbia and Montenegro. Participants either had finished residency or just completed board specialization. They were recommended by national psychiatric associations or international trainees associations. After written application the faculty selected the most promising candidates. The faculty included leading psychiatrists from Germany, India, Switzerland and UK. A second level course with the most active participants from the First and Second Berlin Summer School was held in 2002 (Third Summer School); because the participants of this second level summer school were identical with participants from the first two summer schools and their ratings may have been influenced by being selected for this second level education, the results of the evaluation of this summer school will not be presented here. All former participants (N = 43) of the Berlin Summer School filled out the evaluation form at the end of each summer school, the presented evaluation was pre-planned. The rate of answers varied between 93.3% in 2000; 86.6% in 2001; 93.3% in 2002 and 100% in 2004. The evaluation form included a list of all topics and questioned whether the participants felt that the respective topic was of interest, how the information was conveyed and whether the participants could find the information elsewhere. The answered of each question was scored between 1 = not at all, 2 = not very much, 3 = OK, 4 = very much and 5 = excellent. Evaluation of long-term effects was carried out in 2004 with a questionnaire that was sent via e-mail to all former participants (30) of the summer schools in the years 2000– 2002. We were unable to contact nine participants because their e-mail address has been changed. The former participants were asked whether the training in Berlin had any longterm implications in their professional activities. The answer was rated 5 = yes, very much; 4 = yes a lot; 3 = yes a little; 2 = not very much; 1 = not at all. In addition, with informed consent we present quotations of former participants. For statistical comparison of the different topics of the summer school and the two time points (2000 and 2004) a twofactorial multivariate analysis of variance (MANOVA) was performed. The different topics were regarded as a withinsubjects factor, time was the between-subjects factor. The main and interaction effects of these factors were tested with multivariate criteria such as the Wilks’ lambda and its approximated F-value. When significant main or interaction effects were found, univariate F-tests followed in MANOVA for investigating simple effects. The long-term effects of the Berlin Summer School were studied using a MANOVA compar-
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ing the different topics in a within-subjects design. As a nominal level of significance, alpha = 0.05 was accepted. Bonferroni’s correction was applied to all post hoc tests (P ≤ 0.001). Additionally, a sum score of the overall ratings in 2000 and 2004 were calculated and compared using the Mann–Whitney U-test. In an exploratory analysis we correlated the rating of the participants interest in each topic with the rating of the originality of the presentation (whether the information could be found elsewhere) using Spearman’s linear correlation coefficient.
3. Results 3.1. Evaluation of the first level of the Berlin Summer School—interest in topics, originality of content and quality of presentation MANOVA revealed significant main and interaction effects for the interest in each topic (Wilks’ averaged multivariate tests of significance; effect of topic: F = 9.81, df = 9, 16, P < 0.001; effect of topic × year: F = 11.55, df = 9, 16, P < 0.001), the quality of the different presentations (Wilks’ averaged multivariate tests of significance; effect of topic: F = 33.42, df = 9, 15, P < 0.001; effect of topic × year: F =1 1.90, df = 9, 15, P < 0.001) and whether the information could be found elsewhere (Wilks’ averaged multivariate tests of significance; effect of topic: F = 7.03, df = 9, 15, P = 0.001; effect of topic × year: F = 9.98, df = 9, 15, P < 0.001) (Fig. 1). Further analysis revealed that in 2000 the interest in the topics “How to participate successfully in a congress”, “How
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to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, “How to make a presentation”, “Ethics in research”, “Research and sponsors” and “Clinical Research” were rated significantly higher than in the topics “Depression” or “Epidemiology” (see Fig. 1). Higher ratings in the quality of the presentations were found for “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, “How to make a presentation” and “Substance dependency” when compared to “Ethics in Research”, “Depression” or “Epidemiology” (see Fig. 2). The originality (whether the information could be found elsewhere in 2000) of “Research and sponsors” was rated higher than “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a paper for publication”, “Ethics in research”, and “Clinical Research” “Depression” or “Epidemiology” (see Fig. 3) (P ≤ 0.001, respectively). In 2004 the interest in the topics “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster” and “How to prepare a paper for publication” were rated significantly higher than “How to make a Presentation” and “Substance dependency” (see Fig. 1). The quality of “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, and “Research and Sponsors” scored significantly higher than “How to make a Presentation”, “Substance dependency”, “Depression” or “Epidemiology”. Additionally, “Ethics in Research” scored higher than “Depression” and “Epidemiology” (see Fig. 2). The originality of “How to participate successfully in a congress”, “How to write a CV”, “How to make a Presentation”, “How to prepare a paper for publication”, “Epidemiology” and “How to pre-
Fig. 1. The comparative distribution of mean scores in evaluation: Topic of interest in 2000 and 2004.
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Fig. 2. The comparative distribution of mean scores in the evaluation: Quality of course in 2000 and 2004.
pare a poster” scored higher than “Depression”. Additionally, “How to make a CV” and “Clinical Research” scored higher than “How to make a Presentation” and “Substance dependency” (see Fig. 3) ( P ≤ 0.001). The organizers used this information to plan and organize the next summer schools with more time allotted to these topics. Also the organizers changed some topics like “Depression in old age” into “Depression” or “Psychiatric Epidemiology” into “Mental Health,” cancelled some topics and introduced new topics such as anxiety disorders or schizo-
phrenia. This strategy seems to have been successful, as indicated by a trend towards an increase in the overall ratings for the interest in the presented topics when 2000 was compared to 2004 (Mann–Whitney U-test: P = 0.08). We also assessed the correlation between the interest in the respective lectures and the accessibility of the presented information and observed highly significant correlations for all topics (Spearman’s Rho > 0.49, P < 0.009), which suggest that the lack of information access was associated with an increased interest in the presented topics.
Fig. 3. The comparative distribution of mean scores in the evaluation: “Could you find the information elsewhere?” in 2000 and 2004.
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3.2. Long-term effects of summer school training
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achieved a regular work position in one of the best departments in psychiatry. So, I could say, participation in Berlin Summer School really influence my professional perspective in the best way” (Maja Bajs - Croatia). “I used the presentation skills learned in Berlin in more than 20 oral presentation in national and international congresses. I published several articles, started research work and completed my Ph.D. I keep in contact with former participants and I organized with them workgroups and symposia at different international meetings” (Adriana Mihai – Romania). “The Summer School in Berlin 2002 had valuable contribution in development of my academic career; since then I had very important achievements in my professional development. I was awarded a research grant from the Schering Foundation that supported my project on cross-cultural validation of WHO diagnostic instrument, CIDI, in my native country, Macedonia. Professor Helmchen and Professor Sartorius provided me with valuable supervision during my work on this project. In September 2003, I was awarded with M.Sc. degree in Research Methods in Psychiatry from the Institute of Psychiatry, University of London. The knowledge acquired in Berlin, contributed in developing my skills for writing scientific articles. Subsequently I submitted five articles in high impact journals” (Vesna Jordanova – Macedonia).
In 2004, 52,4% of all former participants of the first level of the Berlin Summer School in the years 2000 and 2001 responded to the question whether their participation in the summer school influenced their professional activities. All previous participants who responded to the questionnaire indicated that the Berlin Summer School influenced their future career, and 22.2% of the participants stated that the summer school training influenced their professional development “a lot” (Table 1). Multivariate analysis revealed a significant main effect of topic (F = 23.00, df = 12, 120, P < 0.001). Further analysis show that the “Contact with other participants” and “Contact with the lecturers” received higher ratings than “Theoretical themes”, “Mental Health issues”, “Contact with representatives of sponsors”, “Ethics” and “How to write an article” (see Table 1). Additionally, “How to produce a poster” was rated to be more influential than “Theoretical issues” and “Contact with representatives of sponsors” and “How to do a presentation” scored higher than “Contact with representatives of sponsors” (P ≤ 0.001). 3.3. Personal comments of participants Some comments reflect the long-term implication of this type of courses: “After Berlin Summer School I did more than 15 poster or oral presentations on national and international meetings, published several articles in high impact journals and received several honors and awards (Research Award 2003 from AEP; a fellowship from Berlin-Brandenburg Academy of Science – Balkan Initiative that supported my stay in Bonn as part of my Ph.D. studies, etc.). I also got my, Ph.D. degree in 2003” (Nadja Maric – Serbia and Montenegro). “In Berlin, one participant introduced me to some contacts in London, which resulted in a research project that included my team in Croatia. Thanks to that, I recently
3.4. Further consequences form the Berlin Summer School: the Eastern European Psychiatric Scientific Initiative—a newly founded network of young psychiatrists The positive reactions of the participants of the first two summer schools stimulated the initiators to organize a second level course. The goal of this course, the Third Berlin Summer School “Psychiatry as a Science,” was to select those previous participants who had shown special research interests and to invite them to a second level course. In this summer school, the participants designed and presented own
Table 1 Long-term evaluation of the Berlin Summer School Objectives for evaluation
Rating 1
Berlin Summer School in general How to make a CV How to write an article How to produce a poster How to do a presentation How to produce a research project Ethical issues Theoretical themes Mental health issues Epidemiological information Contact with other participants Contact with lecturers Contact with representatives of sponsors (foundations, etc.) Materials received
1
2
2 2 2 1 1
4
3 2 5 3 3 2 3 1 3 3 5 2 1 2 6
Mean score 4 4 3 7 3 4 3 6 2 5 2 1 2 3 2
5 5 3 1 5 5 3 2 3 2 3 8 8 2 3
4.27 3.81 3.81 4.18 4.27 3.63 3.72 3.36 3.72 3.63 4.54 4.63 3.27 3.72
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research projects and competed for funding provided by the organizers of the course. Fifteen young psychiatrists form Belgrade, Bucharest, Iasi, Lodz, Prague, Zagreb, Sofia, Skopje, Tirana, and Tg Mures participated at the course in 2002, and presented their project-proposals in different fields of psychiatry: biological psychiatry, social psychiatry, psychotherapy and cross-cultural psychiatry. During the comprehensive and constructive discussions, it became evident that topics and designs of most proposed projects needed some corrections to improve their quality and chances for funding; however, cohesion increased between the participants and they decided that instead of designing individual projects, they preferred to create a group-project that included all participants who agreed to collaborate. Thus, as a spontaneous result of the second level of the Berlin Summer School, a group named E-EPSI has been established. The E-EPSI group immediately prepared and launched a collaborative study in eight Central and Eastern European centers (Romania: Bucharest, Iasi, Tg. Mures, Bulgaria: Sofia, Serbia and Montenegro: Belgrade, Macedonia: Strumica, Croatia: Zagreb, Albania: Tirana) to explore the pathways to psychiatric care in Central and Eastern Europe. The study was completed in 2003 and the manuscript is accepted for publication in the British Journal of Psychiatry. The study was carried out with minimal resources and relied on voluntary work of all previous participants. Nevertheless, this first project of the newly formed group represents the first study that involves the above listed countries, consolidated the E-EPSI group and gave inspiration for future efforts to build an evidence-base for the development of mental health care in Eastern Europe. 4. Discussion The main finding of our analysis of the ratings of the different topics of the Berlin Summer School revealed that practical courses like “How to read a scientific paper”, “How to give a presentation” or “How to design a research project” received higher ratings than theoretical courses like “Epidemiology” or “Depression”. The interest in topics correlated significantly with the originality of the topic and the fact of whether the information is available elsewhere. In the longterm evaluation the topics “How to produce a poster” and “How to do a presentation” were rated most influential. Encountered difficulties in the organization and realization of the Summer School were the uneven knowledge of English and differences in scientific experience and knowledge of the participants as well as problems to extract names of possible candidates from local teachers and psychiatric societies. Although the analysis of the summer school was pre-planned the lack of a control group is one important limitation of our study. In addition the participants were highly motivated and selected and the impact of the course for the further career is difficult to quantify. In the first level courses of the Berlin Summer School, it appeared that medical skills and clinical knowledge of par-
ticipants were sufficient. However, it was evident that most participants lacked sufficient research experience and practical skills in the evaluation of published research articles and in the preparation and presentation of their own research. This observation may reflect the limited opportunities for research that characterized the period of transition and the lack of research funding in Central and Eastern Europe during the last decades. This observation was reflected in the positive evaluation of practical courses that focused on skills like how to read a scientific paper, how to give a presentation or how to design a research project. In most of the participating Central and Eastern European countries, the access to scientific literature and internet databases is rather difficult and expensive [7]. This was reflected in “comments and suggestions” of the participants, an additional part of the yearly evaluation form. In 2004, we expected that the access to information would have improved compared with 2000; however, the participants stated that the information presented in 75% of the courses of the Berlin Summer School would be “very difficult” to obtain otherwise. This rating and the positive evaluation of the originality of the information presented in the practical courses reflect the relative importance of courses that teach skills like dealing with scientific information or planning and presenting their own research findings. Thus, besides knowledge transfer, practical courses for developing skills seem to be pivotal for the success of educational programs like the Berlin Summer School. In addition to knowledge and skills teaching the social and networking aspects of the summer school seem to be very important. This is expressed in the establishment of the Eastern European Scientific Initiative which has stimulated workgroups, symposia, educational and research activities. 4.1. Perspectives: institutionalization of the Berlin Summer School and establishment of national summer schools After completing the first and second level of education given by the Berlin Summer School “Psychiatry as a Science”, and after experiencing practical research during the evaluation of psychiatric care, all participants reported significant improvements in their research abilities and in the development of their professional skills. This positive development is further illustrated by the founding of an independent research network, the E-EPSI group, and its interest to continue collaboration and research with new group-projects. The first three sessions of Berlin Summer School had been supported by the Volkswagen-Stiftung, which provided funds to cover travel and accommodation costs. The positive reaction of the participants stimulated the initiators, as well as the Association of European Psychiatrists (AEP), to undertake steps that would make courses and sessions of the “Berlin Summer School Psychiatry” an annual event. The Fourth Berlin Summer School “Psychiatry as a Science,” was supported by the Lilly Foundation, the “Stifterverband der Deutschen
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Wissenschaft”, “Organon GmbH” and the “Berlin-Brandenburg Academy of Science.” A first national course with a program similar to the first level courses in Berlin was performed in Serbia and Montenegro in late 2004. About 15 selected participants from Serbia had been included in the course. A majority of the lectures was given in English by colleagues who already participated Berlin Summer School(s) or similar courses in Europe. The large number of potential attendants emphasized the high level of interest and motivation to participate, particularly since similar courses in Serbia and Montenegro did not exist before. In conclusion, summer schools provide a promising way for postgraduate training of young psychiatrists. They offer the experience of several courses organized through multilevel education, which can be adapted to every target group with respect to differences and previous experience of the participants. Training of practical skills can improve the research skills of the participants and can be followed by involvement in multicentric and multinational research projects with standardized methods and instruments or in educational national courses organized in a way similar to the Berlin Summer School(s). Furthermore, organizing a selfsustaining network of trainees that creates further postgraduate training courses and summer schools may be a promising way to effectively develop the spectrum of professional skills of young psychiatrists.
Acknowledgements The authors thank Professor Dr. John Cooper, Professor Dr. Sir David Goldberg, Professor Dr. Michael Linden, Professor Dr. S. Murti, Professor Dr. Stefan Priebe, Professor Dr. Dr. Michael Bauer, PD Dr. Georg Juckel, Professor Dr.
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Friedel Reischies, and Professor Dr. L.G. Schmidt for their valuable contributions to the Berlin Summer School Psychiatry. We thank the Volkswagen-Stiftung, the Eli-Lilly International Foundation, the Stifterverband für die Deutsche Wissenschaft, Organon GmbH and the Berlin Brandenburg Academy of Sciences for their support.
References [1]
Camus V, Katona C, de Mendonca Lima CA, Abdel-Hakam AM, Graham N, Baldwin R, et al. Teaching and training in old age psychiatry: a general survey of the World Psychiatric Association member societies. Int J Geriatr Psychiatry 2003;18:683–5. [2] Furedi J, Cooke D. Psychiatric training in Hungary. Eur Arch Clin Neurosci 1997;247(Suppl):S33–4. [3] Hoge MA, Tondora J, Stuart GW. Training in evidence-based practice. Psychiatr Clin North Am 2003;26:851–65. [4] Hohagen F, Treichel S, Berger M. Psychiatric training in Germany. Eur Arch Clin Neurosci 1997;247(Suppl):S15–8. [5] MacDonald J, Cole J. Trainee to trained: helping senior psychiatric trainees make the transition to consultant. Med Educ 2004;38:340–8. [6] Mihai A. Education in psychiatry across Europe Ed. Tg. Mures: UMF; 2002. [7] Mihai A, Nirestean A. Past, present and future in education in psychiatry in Romania. Eur Psychiatry 2002;17(Suppl 1):86. [8] Tinsley JA. An educational intervention to improve residents’ inpatient charting. Acad Psychiatry 2004;28:136–9. [9] UEMS Report of European Board of Psychiatry postgraduate exchange for psychiatric training within the EU countries, 1996 http: //www.uempsychiatry.org/board/reports/pgExchange.pdf. [10] UEMS. Report of the UEMS Section for Psychiatry Continuing Medical Education, 2003 http://www.uemspsychiatry.org/section/reports/ CME.pdf. [11] WPA. World Psychiatric Association institutional program on the core curriculum for postgraduate training in psychiatry, Yokohama, Japan. 2002. [12] Ziherl S. Psychiatric training in Slovenia. Eur Arch Clin Neurosci 1997;247(Suppl):38–40.
Original article
Postgraduate training for young psychiatrists—experience of the Berlin Summer School A. Mihai a, A. Ströhle b,*, N. Maric c, A. Heinz b, H. Helmchen d, N. Sartorius e a
b
Department of Psychiatry, University of Medicine and Pharmacy, Tg. Mures, Romania Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité – University Medicine Berlin, Schumannstr. 20-21, 10117 Berlin, Germany c Institute of Psychiatry, Medical School, University of Belgrade, Clinical Center of Serbia, Belgrade, Serbia and Montenegro d Berlin-Brandenburg Academy of Science, Berlin, Germany e Chemin Colladon 14, 1209 Geneva, Switzerland Received 30 November 2004; accepted 17 May 2005 Available online 08 September 2005
Abstract Background. – Growing professional exchange between Eastern and Western European countries increases the possibilities for international postgraduate training courses and by that satisfying the need for rapid and facilitation of travel and migration in the enlarged European Union increase achieving high standards. The purpose of this study was to evaluate a summer school program that trained young Eastern European psychiatrists and to assess the impact of the program on their professional development and future activities. Method. – We evaluated the training effect of the first 3 years of the Berlin Summer School with respect to (1) the participants’ satisfaction with the topics, quality and originality of the presentations, and (2) long-term effects and implications for their professional career. All participants (N = 43) filled out anonymously the evaluation form at the end of each summer school. An evaluation of long-term effects was carried out 2 years later with a questionnaire that was sent via e-mail to all former participants. Results. – Participants were most satisfied with practical topics such as “how to prepare a paper”, “how to evaluate a paper”, or “how to participate in a congress.” The appreciation of the presented topics and the appreciation of courses increased in each consecutive summer school. All summer school participants reported that the course had some influence on their future career, and one fifth of the participants felt that their professional development was influenced “a lot”. Conclusions. – Although limited to 1 week of intensive training, a summer school program can have a longer lasting positive influence on the professional development of the participants. Participants felt that particularly the training of practical skills improved their research performance. Former participants founded an independent multicentric and multinational research group and supported national courses that were organized similar to the Berlin Summer School. © 2005 Elsevier Masson SAS. All rights reserved. Keywords: Postgraduate training; Psychiatric training; International networks
1. Introduction Developing professional skills is an important goal for trainees and young psychiatrists [10,11]. Young psychiatrists are usually well aware of limitations in their knowledge and professional skills, and understand the need for life-long learning [3,8]. In the recent literature, it has been supposed that trainees and trainers perceive a lack of training in non* Corresponding author. E-mail address: [email protected] (A. Ströhle). 0924-9338/$ - see front matter © 2005 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2005.05.001
clinical skills [5], which would be helpful for the growing professional exchange between Eastern and Western European countries. Facilitation of travel and migration in the enlarged European Union increase the chances for international postgraduate training courses [9] and by that support the need for rapid achieving high standards. In Europe, there is considerable variation in postgraduate training [6,2]. Therefore, international educational programs should keep in mind differences between European countries in terms of duration of residency, programs of education, but also with respect to the clinical and scientific experience and
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demands of young psychiatrists [4,12]. The most adequate development of (clinical and non-clinical) professional skills of European psychiatric trainees may be to organize multilevel courses, which are adapted to each target group and respect differences and previous experiences. Courses may be either international or national; in any case, they will profit from previous experience and exchange with ongoing efforts in postgraduate training (e.g. in old age psychiatry [1]). Here we describe an evaluation of the Berlin Summer School “Psychiatry as a Science” as an example of an international course organized on a multilevel basis and adapted to specific target groups. This Summer School has been educating Central and Eastern European young psychiatrists on a yearly base since 2000 and inspired similar schools and courses to be organized on a national level. The summer school started with several aims that have changed over time. At the beginning, a chief aim was to help in bringing together gifted and promising individuals from countries that came out of a terrible war. The orientation towards practical matters was a result of surveys on postgraduate training, descriptions of trainees and experience with the WPA program on professional skills for young psychiatrists. As a result the program combined practical instructions and review of current knowledge in key areas of psychiatry. Most of the course was organized in an interactive manner and the core faculty members were with the students throughout the time of the course. The purpose of this study was to evaluate the impact of training during the Berlin Summer School on the professional development and future activities of the participants. The effect of this training was evaluated with respect to (1) the participants immediately reported satisfaction with the topics and the quality and originality of the presentations, and (2) the long-term effects and implications for the professional career of the participants. In addition, we will present selected personal comments of participants and describe the Eastern European Psychiatric Scientific Initiative (E-EPSI) as an example for a network which was stimulated by the Berlin Summer School. The institutionalization of the Berlin Summer School and the establishment of national summer schools will be discussed. 2. Subjects, material and methods The Berlin Summer School “Psychiatry as a Science” is organized by the Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité - University Medicine Berlin, in collaboration with the Berlin-Brandenburg Academy of Science. Introductory First level sessions were held in the summer of 2000 (First Berlin Summer School), 2001 (Second Berlin Summer School), and 2004 (Forth Berlin Summer School) and were based on the following educational objectives: • to impart professional skills (such as those involved in reading and presenting a scientific paper, designing and improving own research projects, publishing and presenting results of a study, coping with ethical problems etc.) and;
• to update knowledge in key areas of psychiatry (e.g. epidemiology, schizophrenia, affective disorders, addiction, anxiety disorders, sub-threshold disorders etc.). The topics were presented in highly interactive workshops with a great number of practices and individual tasks. The participants of both first level sessions of Berlin Summer School were 30 young psychiatrists from Central and Eastern European countries: Albania, Bulgaria, Bosnia, Czeck Republic, Croatia, Estonia, Hungary, Macedonia, Poland, Romania, Serbia and Montenegro. Participants either had finished residency or just completed board specialization. They were recommended by national psychiatric associations or international trainees associations. After written application the faculty selected the most promising candidates. The faculty included leading psychiatrists from Germany, India, Switzerland and UK. A second level course with the most active participants from the First and Second Berlin Summer School was held in 2002 (Third Summer School); because the participants of this second level summer school were identical with participants from the first two summer schools and their ratings may have been influenced by being selected for this second level education, the results of the evaluation of this summer school will not be presented here. All former participants (N = 43) of the Berlin Summer School filled out the evaluation form at the end of each summer school, the presented evaluation was pre-planned. The rate of answers varied between 93.3% in 2000; 86.6% in 2001; 93.3% in 2002 and 100% in 2004. The evaluation form included a list of all topics and questioned whether the participants felt that the respective topic was of interest, how the information was conveyed and whether the participants could find the information elsewhere. The answered of each question was scored between 1 = not at all, 2 = not very much, 3 = OK, 4 = very much and 5 = excellent. Evaluation of long-term effects was carried out in 2004 with a questionnaire that was sent via e-mail to all former participants (30) of the summer schools in the years 2000– 2002. We were unable to contact nine participants because their e-mail address has been changed. The former participants were asked whether the training in Berlin had any longterm implications in their professional activities. The answer was rated 5 = yes, very much; 4 = yes a lot; 3 = yes a little; 2 = not very much; 1 = not at all. In addition, with informed consent we present quotations of former participants. For statistical comparison of the different topics of the summer school and the two time points (2000 and 2004) a twofactorial multivariate analysis of variance (MANOVA) was performed. The different topics were regarded as a withinsubjects factor, time was the between-subjects factor. The main and interaction effects of these factors were tested with multivariate criteria such as the Wilks’ lambda and its approximated F-value. When significant main or interaction effects were found, univariate F-tests followed in MANOVA for investigating simple effects. The long-term effects of the Berlin Summer School were studied using a MANOVA compar-
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ing the different topics in a within-subjects design. As a nominal level of significance, alpha = 0.05 was accepted. Bonferroni’s correction was applied to all post hoc tests (P ≤ 0.001). Additionally, a sum score of the overall ratings in 2000 and 2004 were calculated and compared using the Mann–Whitney U-test. In an exploratory analysis we correlated the rating of the participants interest in each topic with the rating of the originality of the presentation (whether the information could be found elsewhere) using Spearman’s linear correlation coefficient.
3. Results 3.1. Evaluation of the first level of the Berlin Summer School—interest in topics, originality of content and quality of presentation MANOVA revealed significant main and interaction effects for the interest in each topic (Wilks’ averaged multivariate tests of significance; effect of topic: F = 9.81, df = 9, 16, P < 0.001; effect of topic × year: F = 11.55, df = 9, 16, P < 0.001), the quality of the different presentations (Wilks’ averaged multivariate tests of significance; effect of topic: F = 33.42, df = 9, 15, P < 0.001; effect of topic × year: F =1 1.90, df = 9, 15, P < 0.001) and whether the information could be found elsewhere (Wilks’ averaged multivariate tests of significance; effect of topic: F = 7.03, df = 9, 15, P = 0.001; effect of topic × year: F = 9.98, df = 9, 15, P < 0.001) (Fig. 1). Further analysis revealed that in 2000 the interest in the topics “How to participate successfully in a congress”, “How
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to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, “How to make a presentation”, “Ethics in research”, “Research and sponsors” and “Clinical Research” were rated significantly higher than in the topics “Depression” or “Epidemiology” (see Fig. 1). Higher ratings in the quality of the presentations were found for “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, “How to make a presentation” and “Substance dependency” when compared to “Ethics in Research”, “Depression” or “Epidemiology” (see Fig. 2). The originality (whether the information could be found elsewhere in 2000) of “Research and sponsors” was rated higher than “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a paper for publication”, “Ethics in research”, and “Clinical Research” “Depression” or “Epidemiology” (see Fig. 3) (P ≤ 0.001, respectively). In 2004 the interest in the topics “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster” and “How to prepare a paper for publication” were rated significantly higher than “How to make a Presentation” and “Substance dependency” (see Fig. 1). The quality of “How to participate successfully in a congress”, “How to write a CV”, “How to prepare a poster”, “How to prepare a paper for publication”, and “Research and Sponsors” scored significantly higher than “How to make a Presentation”, “Substance dependency”, “Depression” or “Epidemiology”. Additionally, “Ethics in Research” scored higher than “Depression” and “Epidemiology” (see Fig. 2). The originality of “How to participate successfully in a congress”, “How to write a CV”, “How to make a Presentation”, “How to prepare a paper for publication”, “Epidemiology” and “How to pre-
Fig. 1. The comparative distribution of mean scores in evaluation: Topic of interest in 2000 and 2004.
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Fig. 2. The comparative distribution of mean scores in the evaluation: Quality of course in 2000 and 2004.
pare a poster” scored higher than “Depression”. Additionally, “How to make a CV” and “Clinical Research” scored higher than “How to make a Presentation” and “Substance dependency” (see Fig. 3) ( P ≤ 0.001). The organizers used this information to plan and organize the next summer schools with more time allotted to these topics. Also the organizers changed some topics like “Depression in old age” into “Depression” or “Psychiatric Epidemiology” into “Mental Health,” cancelled some topics and introduced new topics such as anxiety disorders or schizo-
phrenia. This strategy seems to have been successful, as indicated by a trend towards an increase in the overall ratings for the interest in the presented topics when 2000 was compared to 2004 (Mann–Whitney U-test: P = 0.08). We also assessed the correlation between the interest in the respective lectures and the accessibility of the presented information and observed highly significant correlations for all topics (Spearman’s Rho > 0.49, P < 0.009), which suggest that the lack of information access was associated with an increased interest in the presented topics.
Fig. 3. The comparative distribution of mean scores in the evaluation: “Could you find the information elsewhere?” in 2000 and 2004.
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3.2. Long-term effects of summer school training
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achieved a regular work position in one of the best departments in psychiatry. So, I could say, participation in Berlin Summer School really influence my professional perspective in the best way” (Maja Bajs - Croatia). “I used the presentation skills learned in Berlin in more than 20 oral presentation in national and international congresses. I published several articles, started research work and completed my Ph.D. I keep in contact with former participants and I organized with them workgroups and symposia at different international meetings” (Adriana Mihai – Romania). “The Summer School in Berlin 2002 had valuable contribution in development of my academic career; since then I had very important achievements in my professional development. I was awarded a research grant from the Schering Foundation that supported my project on cross-cultural validation of WHO diagnostic instrument, CIDI, in my native country, Macedonia. Professor Helmchen and Professor Sartorius provided me with valuable supervision during my work on this project. In September 2003, I was awarded with M.Sc. degree in Research Methods in Psychiatry from the Institute of Psychiatry, University of London. The knowledge acquired in Berlin, contributed in developing my skills for writing scientific articles. Subsequently I submitted five articles in high impact journals” (Vesna Jordanova – Macedonia).
In 2004, 52,4% of all former participants of the first level of the Berlin Summer School in the years 2000 and 2001 responded to the question whether their participation in the summer school influenced their professional activities. All previous participants who responded to the questionnaire indicated that the Berlin Summer School influenced their future career, and 22.2% of the participants stated that the summer school training influenced their professional development “a lot” (Table 1). Multivariate analysis revealed a significant main effect of topic (F = 23.00, df = 12, 120, P < 0.001). Further analysis show that the “Contact with other participants” and “Contact with the lecturers” received higher ratings than “Theoretical themes”, “Mental Health issues”, “Contact with representatives of sponsors”, “Ethics” and “How to write an article” (see Table 1). Additionally, “How to produce a poster” was rated to be more influential than “Theoretical issues” and “Contact with representatives of sponsors” and “How to do a presentation” scored higher than “Contact with representatives of sponsors” (P ≤ 0.001). 3.3. Personal comments of participants Some comments reflect the long-term implication of this type of courses: “After Berlin Summer School I did more than 15 poster or oral presentations on national and international meetings, published several articles in high impact journals and received several honors and awards (Research Award 2003 from AEP; a fellowship from Berlin-Brandenburg Academy of Science – Balkan Initiative that supported my stay in Bonn as part of my Ph.D. studies, etc.). I also got my, Ph.D. degree in 2003” (Nadja Maric – Serbia and Montenegro). “In Berlin, one participant introduced me to some contacts in London, which resulted in a research project that included my team in Croatia. Thanks to that, I recently
3.4. Further consequences form the Berlin Summer School: the Eastern European Psychiatric Scientific Initiative—a newly founded network of young psychiatrists The positive reactions of the participants of the first two summer schools stimulated the initiators to organize a second level course. The goal of this course, the Third Berlin Summer School “Psychiatry as a Science,” was to select those previous participants who had shown special research interests and to invite them to a second level course. In this summer school, the participants designed and presented own
Table 1 Long-term evaluation of the Berlin Summer School Objectives for evaluation
Rating 1
Berlin Summer School in general How to make a CV How to write an article How to produce a poster How to do a presentation How to produce a research project Ethical issues Theoretical themes Mental health issues Epidemiological information Contact with other participants Contact with lecturers Contact with representatives of sponsors (foundations, etc.) Materials received
1
2
2 2 2 1 1
4
3 2 5 3 3 2 3 1 3 3 5 2 1 2 6
Mean score 4 4 3 7 3 4 3 6 2 5 2 1 2 3 2
5 5 3 1 5 5 3 2 3 2 3 8 8 2 3
4.27 3.81 3.81 4.18 4.27 3.63 3.72 3.36 3.72 3.63 4.54 4.63 3.27 3.72
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research projects and competed for funding provided by the organizers of the course. Fifteen young psychiatrists form Belgrade, Bucharest, Iasi, Lodz, Prague, Zagreb, Sofia, Skopje, Tirana, and Tg Mures participated at the course in 2002, and presented their project-proposals in different fields of psychiatry: biological psychiatry, social psychiatry, psychotherapy and cross-cultural psychiatry. During the comprehensive and constructive discussions, it became evident that topics and designs of most proposed projects needed some corrections to improve their quality and chances for funding; however, cohesion increased between the participants and they decided that instead of designing individual projects, they preferred to create a group-project that included all participants who agreed to collaborate. Thus, as a spontaneous result of the second level of the Berlin Summer School, a group named E-EPSI has been established. The E-EPSI group immediately prepared and launched a collaborative study in eight Central and Eastern European centers (Romania: Bucharest, Iasi, Tg. Mures, Bulgaria: Sofia, Serbia and Montenegro: Belgrade, Macedonia: Strumica, Croatia: Zagreb, Albania: Tirana) to explore the pathways to psychiatric care in Central and Eastern Europe. The study was completed in 2003 and the manuscript is accepted for publication in the British Journal of Psychiatry. The study was carried out with minimal resources and relied on voluntary work of all previous participants. Nevertheless, this first project of the newly formed group represents the first study that involves the above listed countries, consolidated the E-EPSI group and gave inspiration for future efforts to build an evidence-base for the development of mental health care in Eastern Europe. 4. Discussion The main finding of our analysis of the ratings of the different topics of the Berlin Summer School revealed that practical courses like “How to read a scientific paper”, “How to give a presentation” or “How to design a research project” received higher ratings than theoretical courses like “Epidemiology” or “Depression”. The interest in topics correlated significantly with the originality of the topic and the fact of whether the information is available elsewhere. In the longterm evaluation the topics “How to produce a poster” and “How to do a presentation” were rated most influential. Encountered difficulties in the organization and realization of the Summer School were the uneven knowledge of English and differences in scientific experience and knowledge of the participants as well as problems to extract names of possible candidates from local teachers and psychiatric societies. Although the analysis of the summer school was pre-planned the lack of a control group is one important limitation of our study. In addition the participants were highly motivated and selected and the impact of the course for the further career is difficult to quantify. In the first level courses of the Berlin Summer School, it appeared that medical skills and clinical knowledge of par-
ticipants were sufficient. However, it was evident that most participants lacked sufficient research experience and practical skills in the evaluation of published research articles and in the preparation and presentation of their own research. This observation may reflect the limited opportunities for research that characterized the period of transition and the lack of research funding in Central and Eastern Europe during the last decades. This observation was reflected in the positive evaluation of practical courses that focused on skills like how to read a scientific paper, how to give a presentation or how to design a research project. In most of the participating Central and Eastern European countries, the access to scientific literature and internet databases is rather difficult and expensive [7]. This was reflected in “comments and suggestions” of the participants, an additional part of the yearly evaluation form. In 2004, we expected that the access to information would have improved compared with 2000; however, the participants stated that the information presented in 75% of the courses of the Berlin Summer School would be “very difficult” to obtain otherwise. This rating and the positive evaluation of the originality of the information presented in the practical courses reflect the relative importance of courses that teach skills like dealing with scientific information or planning and presenting their own research findings. Thus, besides knowledge transfer, practical courses for developing skills seem to be pivotal for the success of educational programs like the Berlin Summer School. In addition to knowledge and skills teaching the social and networking aspects of the summer school seem to be very important. This is expressed in the establishment of the Eastern European Scientific Initiative which has stimulated workgroups, symposia, educational and research activities. 4.1. Perspectives: institutionalization of the Berlin Summer School and establishment of national summer schools After completing the first and second level of education given by the Berlin Summer School “Psychiatry as a Science”, and after experiencing practical research during the evaluation of psychiatric care, all participants reported significant improvements in their research abilities and in the development of their professional skills. This positive development is further illustrated by the founding of an independent research network, the E-EPSI group, and its interest to continue collaboration and research with new group-projects. The first three sessions of Berlin Summer School had been supported by the Volkswagen-Stiftung, which provided funds to cover travel and accommodation costs. The positive reaction of the participants stimulated the initiators, as well as the Association of European Psychiatrists (AEP), to undertake steps that would make courses and sessions of the “Berlin Summer School Psychiatry” an annual event. The Fourth Berlin Summer School “Psychiatry as a Science,” was supported by the Lilly Foundation, the “Stifterverband der Deutschen
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Wissenschaft”, “Organon GmbH” and the “Berlin-Brandenburg Academy of Science.” A first national course with a program similar to the first level courses in Berlin was performed in Serbia and Montenegro in late 2004. About 15 selected participants from Serbia had been included in the course. A majority of the lectures was given in English by colleagues who already participated Berlin Summer School(s) or similar courses in Europe. The large number of potential attendants emphasized the high level of interest and motivation to participate, particularly since similar courses in Serbia and Montenegro did not exist before. In conclusion, summer schools provide a promising way for postgraduate training of young psychiatrists. They offer the experience of several courses organized through multilevel education, which can be adapted to every target group with respect to differences and previous experience of the participants. Training of practical skills can improve the research skills of the participants and can be followed by involvement in multicentric and multinational research projects with standardized methods and instruments or in educational national courses organized in a way similar to the Berlin Summer School(s). Furthermore, organizing a selfsustaining network of trainees that creates further postgraduate training courses and summer schools may be a promising way to effectively develop the spectrum of professional skills of young psychiatrists.
Acknowledgements The authors thank Professor Dr. John Cooper, Professor Dr. Sir David Goldberg, Professor Dr. Michael Linden, Professor Dr. S. Murti, Professor Dr. Stefan Priebe, Professor Dr. Dr. Michael Bauer, PD Dr. Georg Juckel, Professor Dr.
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Friedel Reischies, and Professor Dr. L.G. Schmidt for their valuable contributions to the Berlin Summer School Psychiatry. We thank the Volkswagen-Stiftung, the Eli-Lilly International Foundation, the Stifterverband für die Deutsche Wissenschaft, Organon GmbH and the Berlin Brandenburg Academy of Sciences for their support.
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