Patient-centered curricula at the University of Geneva: opening the door to psychotherapy training.

An increasing importance is given today to social and behavioural sciences in medical education in most developed countries. The goal is to ensure that trained medical students are ‘fit to purpose’ as stated in an editorial of the British Medical Journal [1]. We believe that a central component of this task is to promote interest towards ‘patientcentered care’ in future medical doctors. This short paper will focus on two patient-centered medical education initiatives which takes place at the beginning and end of the medical curriculum at the University of Geneva:


Introduction
An increasing importance is given today to social and behavioural sciences in medical education in most developed countries. The goal is to ensure that trained medical students are 'fit to purpose' as stated in an editorial of the British Medical Journal [1]. We believe that a central component of this task is to promote interest towards 'patientcentered care' in future medical doctors. This short paper will focus on two patient-centered medical education initiatives which takes place at the beginning and end of the medical curriculum at the University of Geneva: The 'Person, Health and Society' program, which takes place during the first year of the medical curriculum 1.
and Integrated psychotherapy, which takes place during the pre-and postgraduate training periods in psychiatry. 2.

The 'Person, Health and Society' program
The goals of this newly created program are to instill, in first-year medical students, an understanding of various psychosocial determinants of health and disease at the individual and community levels.
Interactions with individuals of a wide range of ages and cultural backgrounds within a bio-psycho-social frame-work are at the core of the curriculum, which focuses on diverse issues, such as chronicity, complexity, multidisciplinary approaches, ethical dimensions, and social and emotional determinants of health. Special care is given to foster respect for differences, critical thinking, receptiveness to self-criticism, and open-mindedness.
The questioning of social issues in medicine is addressed, as well as sociological, anthropological, and com-munity aspects of the medical encounter. Overall, the main goal of the program is to train medical students to become what has been called 'good doc-tors', which beyond doubt implies being 'patient-sensitive doctors'.
The main themes addressed in the Person, Health and Society Program are shown in the box below: The bio-psycho-social model of health and illness -Cure and care concepts/stigmatisation issues -Medical psychology including its influence on behaviour and care seeking -Behavioural medicine, including neurobiological and interpersonal aspects -Communication issues -Doctor-patient relationships -Decision analysis from epidemiology to patients' representations -Ethical and deontological issues -International Journal of Integrated Care -Vol. 10, 29 January 2010 -ISSN 1568-4156 -http://www.ijic.org/ Development of the person from the newborn to the aging adult; changes and crises throughout the lifecycle -Chronic diseases and health enhancement - The health system and its organisation; access to health care -Human rights and health; social inequalities and health -Emotional and social determinants of health and disease -

Faculty and setting
The 100-hour program represents 20% of the total first-year curriculum and exam questions.
Due to the large number of students (>400), classical lectures alternate with video presentations of patients and seminars in smaller groups where subjective and interpersonal issues can be raised.
The multidisciplinary faculty includes general hospital internists, community-based primary care physicians and specialists from the social sciences. The involvement of faculty with formal expertise in behavioural and social sciences may raise issues of acceptance and identity but should be strongly encouraged [2,3].

Discussion
Inserting a program at such an early stage of medical education is a challenge due to the students' lack of clinical experience. It does, however, have the advantage of making students aware of behavioural and interpersonal issues at a very early stage of their medical studies. It should also be seen as a platform to facilitate the implementation of patient-centered attitudes and curricula in later years.

The importance of the double title of specialist in psychiatry and psychotherapy to advocate individualized medicine
Postgraduate training of psychiatrists includes two aspects: psychiatry and psychotherapy [4].
This rather unique situation, which exists today in Switzerland, can be traced back more than half a century and owes a great deal to the influence of a few outstanding personalities in Swiss psychiatry [5].
From a historical point of view, the first crucial decision was made in 1931 to separate psychiatry and neurology. Beginning in 1935, Swiss psychotherapists organized regular meetings which resulted in two distinct societies: the Swiss society of medical psychotherapy, with Oscar Forel as president, and the Swiss society of psychology, with Carl-Gustav Jung as president.
In 1957, the distinction is made between the titles of adult psychiatry and child and adolescent psychiatry, and in 1960, the double title of specialist in psychiatry and psychotherapy is introduced.
Concerning the audit of the quality of the training, the situation has steadily evolved: beginning in 1960, every psychiatrist-psychotherapist must undertake several supervised psychotherapy sessions.
After extended debate, a personal experience of undetermined length becomes mandatory at the end of the 1990s, but it is only since this year (2008) that the minimum length has been set at 100 hours. As a whole, the theoretical training in psychiatry and psychotherapy is spread over 5 years, with an additional year in another clinical branch.
The programme includes 2 years devoted to integrative psychiatric psychotherapy treatment, as well as the fundamentals of several models of psychotherapy. During the 3rd year, residents choose to deepen their theoretical and practical knowledge of one of the psychotherapy models (psychoanalytical, family-systemic, cognitive behaviour). In principal, all of the psychotherapy experience takes place under supervision, for a total of 150 hours of IPPT (integrative psychiatric psychotherapy treatment) and 150 hours of psychotherapy.
At the end of their training curriculum, which is validated by an exam, the specialists in psychiatry and psychotherapy can further their knowledge, for example through five continuing training programmes that we have set up at the University of Geneva, each one leading to a certification or a diploma [in cognitive behaviour, family-systemic, psychoanalytic, dialectical behaviour (DBT) therapy and in psychosocial and psychosomatic medicine].

Conclusion
We believe that a medical practice centered on the individual must be integrated within the programme from the 1st year of medical school. It should raise awareness to medical approaches concentrating on individuals. As such the curriculum must also make medical students aware of the psychotherapy aspect of treatments and an intensive postgraduate training programme in psychiatry and psychotherapy seems to be an appropriate solution to continue to attract young doctors to psychiatry.