The effective management of patients with anxiety, depressive disorder or somatisation, who commonly present across all medical disciplines, requires an understanding of both psychological and pharmacological treatments. ^1-3 The UK's Improving Access to Psychological Therapies (IAPT; www.iapt.nhs.uk) multimillion pound programme reflects a political commitment to a stepped-care model of care for patients, with an emphasis on cognitive-behavioural therapy (CBT). It is therefore important for doctors to have an awareness of basic cognitive-behavioural principles and skills, together with an understanding of which patients might derive benefit. Medical education, which has traditionally focused on a pharmacological approach, needs to evolve to reflect this. ^{Reference Mayou4,Reference Le Fevre and Goldbeck5}

There are no published reports of CBT teaching for medical students and little research addressing the delivery of relevant training for health professionals who are not planning to be career cognitive therapists. ^{Reference Kerwick, Jones, Mann and Goldberg6,Reference Sholomskas and Syracuse-Siewert7} A randomised trial of 116 general practitioners (GPs) in the UK found that a training package of four half-day sessions about brief CBT for depression, which did not include an opportunity to practise skills through supervised casework, had no impact on the GPs' knowledge and attitudes towards depression. ^{Reference Westbrook, Sedgewick-Taylor, Bennett-Levy, Butler and McManus8} The form of training may be important - two before-and-after studies in the UK and Canada evaluating CBT training for 20 palliative care practitioners and 34 mental health practitioners, in which the educational programme did incorporate supervised casework, demonstrated effective learning of skills. ^{Reference King, Davidson, Taylor, Haines, Sharp and Turner9,Reference Lau, Dubord and Parikh10} Training also needs to focus on teaching skills that are feasible for use in the practitioners' routine setting. ^{Reference Mannix, Blackburn, Garland, Gracie, Moorey and Reid11,Reference Murrihy and Byrne12}

This paper describes and evaluates an innovative cognitive-behavioural skills training programme for medical students, which includes a clinical opportunity to take enhanced responsibility for patient care.

Method

Results

Main findings

Students

The overall rating of the course by students was very positive: 71% ranked the learning experience as excellent and 27% as good; 82% would definitely recommend the course to another medical student who was interested in participating.

Acceptability to patients

Of the 23 patients who were sent satisfaction questionnaires, 15 responded: 47% felt very satisfied, 40% mildly satisfied and 13% mildly dissatisfied; 72% were very or mostly happy to see a medical student and 79% rated the quality of care received as good or excellent. Data collection of standardised clinical measures after the self-help intervention was incomplete and is not reported.

Change in knowledge, skills and attitudes

Students reported marked improvements in their knowledge and skills related to CBT after the training and felt significantly more convinced of both its effectiveness for patients and its relevance for doctors. Figure 1 shows both the increase in learning as a result of the experiential workshops and the additional benefit of the clinical experience. Qualitative data showed that the supervised casework changed students' attitudes towards using CBT in clinical practice.

Fig 1 Change in knowledge, skills and attitudes before and after training (n = 42). CBT, cognitive-behavioural therapy.

Seeing how it made a difference with someone definitely helped me… people were sceptical after the lecture… so it was useful to have a positive experience. (Student 1)

I am more willing as a clinician to consider non-medical therapies in the management of patients. (Student 2)

I learned a skill that I would not otherwise have thought was important to clinical practice. (Student 3)

Enhanced responsibility for patient care

Students had particularly valued the opportunity to take a greater level of responsibility for patient care; 96% rated this greatly (5) or very much (4) on a 5-point Likert scale. For many students the experience was empowering.

It's the first time that a patient was coming specifically to see you - that's a different sense of responsibility which was a really positive thing. (Student 1)

It was challenging and rewarding to take on the role of a therapist… to be directly involved in patient care and be treated more like a doctor. (Student 4)

Sometimes you get a bit downhearted as a student - it was a real confidence booster. (Student 5)

The majority of students (89%) reported having had no other opportunities to take a similar level of responsibility during the medical course - but all indicated on a 4-point Likert scale that they would ‘definitely’ or ‘probably’ value more opportunities to do this.

Reflection and learning concerning professional in addition to clinical issues occurred as a result of the students taking responsibility for the guided self-help sessions. The weekly group supervision was an opportunity for discussion and support from peers as well as tutors. Having time to focus in depth on a particular patient was also felt to enhance learning.

It helped me to reflect on my professional responsibilities as a doctor, to prepare for patient care, ensure sessions were organised and that care progressed. (Student 6)

Even if you are on a medical ward seeing a patient for 6 or 8 weeks you still haven't spent 3 hours talking to them in all that time. (Student 7)

Generic skills

Although the primary aim of the programme was to teach medical students about CBT, it emerged from both qualitative and quantitative data that it had also been a vehicle for generic learning about communication skills and common mental health problems. A significant proportion of students believed their skills and clinical knowledge had improved ‘moderately’ or ‘very much’ (on a 4-point Likert scale; communication stills - 73%, clinical skills relating to mental health - 75%, clinical knowledge relating to mental health - 43%). Fewer students reported improvements in clinical knowledge; this reflects a variety of clinical experiences and baseline knowledge but also demonstrates that the students did not automatically report that they had benefited from the training. Qualitative feedback revealed benefits relating to structuring the consultation, setting achievable goals, facilitating patient participation and using active listening skills together with increased insight into the patient experience of having a mental health problem.

Looking back, I was amazed how little I knew about the massive impact of such a common problem as depression and believe this experience will change the way I interact with similar patients in the future. (Student 8)

To have the role as the therapist and not be the friend, to take a step back and redirect and focus things. (Student 9)

Giving a structure to the meeting… setting an agenda together at the beginning. (Student 7)

Prompting patients to draw their own conclusions is more effective than giving advice. (Student 10)

Most students (91%) felt that they had ‘probably’ or ‘definitely’ been able to help the patient and this had been rewarding (Box 2); 42% students commented that time to talk had been helpful for the patient.

I'd like to think it helps who you are talking to as well. It's a two-way street - you learn and the patient gets something out of it as well. (Student 7)

Patients value a sympathetic objective listener, however inexperienced. (Student 11)

Need for support and supervision

Students reported the need to feel well supported, both professionally and emotionally, during the clinical experience; 98% students felt that there had probably or definitely been sufficient access to supervision when seeing the patient (4-point Likert scale).

I was very nervous in my first session and came out quite despondent - however, I received brilliant support following this. (Student 12)

If I'd felt it was just down to me that would have been awful. (Student 1)

Problems identified

The majority of students reported that there had been no problems with the training. Several students mentioned patient non-attendance or unsuitability for CBT, difficulty with fitting the experience in with their psychiatry placement, especially if this was outside Oxford, or logistic issues such as room availability. The most commonly reported problem was oversubscription of places for the clinical experience, with some students missing an opportunity they were keen to take up.

Discussion

The CBT skills training programme was feasible, sustainable and highly valued by students, who particularly appreciated the opportunity to take responsibility for patient care. Students reported learning not only about cognitive-behavioural interventions but also generic skills related to becoming a practitioner such as communication skills and understanding of mental health problems. Within the well-supported framework of group supervision, the challenge of taking the role of therapist was empowering, allowing the student to experience positive feedback related to treating a patient. Students reported having few other opportunities to do this during their undergraduate medical training but overwhelmingly expressed a desire to do so. The student-delivered intervention was found to be acceptable to patients, some of whom derived clinical benefit and did not need further psychological help.

The addition of the clinical experience to the class-based workshops enhanced learning about CBT relevance and effectiveness. It allowed the students to practise using cognitive-behavioural strategies with patients; some of those strategies might be transferable to a medical consultation, such as behavioural activation, identifying and challenging negative thinking and guided self-help. Strategies to elicit and address the cognitive and behavioural factors contributing to medical conditions can be very helpful for doctors. Failing to elicit a patient's ideas and concerns about symptoms and failure to address behavioural factors may lead to persistence of symptoms, repeated consultation and inappropriate referral or treatment, which has costs not only for patients and their carers but also the healthcare system as a whole. ^{Reference Beck, Steer and Brown17,Reference Kroenke18}

Students reported that having time to focus in depth on one patient with the support of an experienced practitioner particularly facilitated their learning. In line with similar interventions for qualified practitioners, supervised casework appeared to be an effective format which had particular value for medical students as it allowed them more responsibility than usual for patient care and was an opportunity to practise and reflect on professionalism.

Self-report was a valid way to explore the learners' experience of the training, particularly as we based our questionnaire on information which was derived from in-depth interviews with the learners themselves. However, it was a less robust method for assessing change in knowledge and skills as it has been shown that estimates of improvement made by individual doctors may be optimistic when compared with objective measures. ^{Reference Layard19} Responses to the questions related to knowledge and skills should therefore be interpreted with some caution, especially as the data collection was retrospective. Nevertheless, there were consistent trends and a substantial increase in learning before and after training, which were reported by students in separate groups across three consecutive year groups. Within the sample, we noted evidence of variability in self-reported improvement in different areas of learning, suggesting both an ability and willingness to be discriminating. These factors, together with the alignment of the qualitative and quantitative responses, strengthen the internal validity of the questionnaire. A particular advantage of the mixed-methods approach was demonstrated by the emergence of themes related to the value of taking responsibility and learning generic skills, which we had not anticipated.

Although the students could remain anonymous when replying to the semi-quantitative questionnaire, their relationship with both teachers may have coloured the responses, which were very positive. Some students may have felt unable to be critical of the programme. There was also a potential for bias in the study concerning interpretation of the qualitative data.

Conclusions

Undergraduate education would be enhanced by the introduction of CBT training. It would be highly desirable to create more opportunities for students to take some responsibility for patient care as this could facilitate professional development. ^{Reference Davis, Mazmanian, Fordis, Van Harrison, Thorpe and Perrier20} It was recently recommended by the General Medical Council that ‘clinical placements should move the student systematically to a more central role before they take on responsibilities of an FY1’. ^{Reference Howe21}

Training encouraged positive attitudes towards psychological approaches and raised student awareness of their relevance for doctors, therefore it seems well placed within an undergraduate curriculum. The interprofessional teaching format overcame the problem that at present few doctors are sufficiently skilled to teach CBT skills. The involvement of a medical practitioner in addition to a psychologist ensured students perceived how and why the training was relevant for them.

Is our training programme a generalisable model? A high level of student support and commitment from both clinical psychologist and GP is required. However, it may be possible in the future for the IAPT programme to provide opportunities for supporting and supervising medical students undertaking this type of clinical experience. In our study, students were self-selecting and motivated; as it is a challenging experience it is possible that less confident students could be overwhelmed rather than empowered. It also requires appropriate patient selection.