Background: The James Cook University (JCU) medical school recently revised its Year 2 human development and behaviour module to be more relevant and practical for students, and more aligned with the mental health priorities of the local region (north Queensland). This study reports medical students’ level of preparedness conferred by the re-designed ‘Psychological Medicine and Human Development’ (PMHD) subject for their later 4-week, rural clinical placement in Year 2. Methods: Non-randomized, controlled ‘naturalistic’ study with pre- and post-intervention surveys. The patient mental health experiences of Year 2 students who went on clinical placement after undertaking the PMHD subject were compared to those who went on placement before undertaking PMHD. Results: A total of 209 JCU Year 2 medical students completed surveys from a possible 217 (response rate = 96%). Compared to students whom had not taken PMHD before going on placement, students going on placement after undertaking PMHD were significantly more likely to report: feeling comfortable discussing mental health issues with patients (p = 0.001); being prepared for mental health discussions with patients (p < 0.001); having an actual mental health discussion with a patient (p < 0.001); and, volunteering an opinion on the appropriateness of their supervising doctor’s response (p < 0.001). Students reported subject content involving information and classroom instruction on assessing and interviewing patients for mental illness to be of most use. Conclusions: Providing medical students with psychological medicine information on locally prevalent mental health conditions plus practical classroom experiences in conducting mental state exams better prepares them for interacting with patients experiencing psychological distress. This novel methodology – aligning formal teaching in a subject with an evaluation utilizing a proximate student placement to provide useful feedback on the curriculum content and assess the relevance of the material taught – could be used to revise other content areas of a medical course to be more locally relevant and practically focused, and then to evaluate the success of this revision. Keywords: Psychological, Medicine, Undergraduate, Student, Rural, Mental, Health, Curriculum * Correspondence: email@example.com College of Medicine and Dentistry, James Cook University, QLD, Townsville 4811, Australia © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 2 of 7 Background particularly vulnerable to experiencing high levels of Ensuring medical education reflects and is responsive to stress  and serious mental illness such as psychosis, the priority healthcare needs of local communities is be- with a rate of almost 15 times the non-Indigenous popu- coming a focus for reform internationally. However, lation  (44.9 per 1000 population compared to 2.9 per many medical schools, charged with producing tomor- 1000 population for non-Indigenous young people row’s doctors, have been criticised for having a curricu- Australia wide). lum that does not always reflect the priority needs of the JCU’s psychological medicine subject was re-designed local region, or give priority to the most vulnerable indi- in 2013 from one with a predominant focus on human viduals and groups in society . development and behaviour into the current ‘Psycho- However, the undergraduate entry Bachelor of Medi- logical Medicine and Human Development’ (PMHD) cine, Bachelor of Surgery (MBBS) James Cook University subject. This revised PMHD subject predominantly tea- (JCU) medical school was established in North Queens- ches students ‘biopsychosocial’ perspectives of health land (NQ) in 2000  with a curriculum aligned with (the psychological and behavioural factors influencing the health priorities of the north Queensland/northern health and illness), as well as the more general, practical Australian region, in particular, Aboriginal and Torres skills required to interview and diagnose patients with a Strait Islander peoples – the most disadvantaged and mental health condition. This re-design was undertaken vulnerable group in the country. in part to better align the subject with the medical Due to this ‘socially-accountable’ philosophy, in 2008 school’s ‘socially-accountable’ mandate of addressing the the JCU medical school joined a world-wide consortium priority health needs of the local region and the most of 12 health professional schools called the Training for vulnerable Aboriginal and Torres Strait Islander popula- Health Equity Network (THEnet). THEnet is committed tions. In addition, the re-design was undertaken to make to achieving health equity through transforming health the subject more practical, as there is evidence that de- professional education to meet local needs [3, 4]. All 12 velopmental and mental health subjects in early medical THEnet medical schools have similar socially-accountable courses are commonly perceived by students to be of lit- philosophies and curriculum approaches, including equit- tle relevance or value , even though studies demon- able selection processes for admitting rural applicants strate high levels of mental health disorders treated by and/or applicants from underserved sub-populations, a doctors in hospitals  and in the community (particu- curriculum that is responsive to the priority health issues larly in rural general practice) . of the local region, and mandatory service learning for This re-design was informed by student feedback ses- students in rural communities involving significant in- sions immediately after their Year 2 rural community volvement with local community members. placements in 2013, which discussed the frequency and For example, the JCU medical curriculum includes the variety of patient mental health presentations seen on requirement that all Year 2 students must pass the placement, and the competencies required to undertake ‘Rural, Remote, Indigenous and Tropical Health’ subject, a focused mental health history and examination. On as well as a mandatory 4-week rural placement to intro- Year 2 community placements, students are required to duce them to local rural communities and their health undertake history and examinations on the rural general issues (including 1 week in an Aboriginal Medical Ser- practice patient population, which is known to include a vice), and have experiences in rural hospital wards and high proportion of patients experiencing psychological rural medical centres focussed on patient history-taking distress, as well as a high proportion of Aboriginal and and examinations, including around mental health. Torres Strait Islander peoples whom many also experi- Also in Year 2, the JCU medical school delivers a psy- ence psychological distress. For example, in the remote chological medicine subject, which is part of an overall region of Mount Isa, where about 25% of JCU Year 2 linkage of psychological issues that is built upon by later medical students spend their Year 2 community place- modules and curriculum activities in the 6 year course. ment, 23% of the population are Aboriginal and Torres Having a subject dedicated to psychological medicine at Strait Islander peoples; much higher than the national the JCU medical school is important. Not only is the average of 3% (http://www.censusdata.abs.gov.au/cen- base rate of mental health disorders in the Australian sus_services/getproduct/census/2016/quickstat/ community high, with a lifetime risk of 45% for adults SED30057). Discussions highlighted the high incidence aged 16–85 , but regional and remote areas of of students coming into contact with patients experien- Australia are at even greater risk for these disorders . cing psychological distress, and students’ lack of confi- In addition, it is well recognised that Aboriginal and dence and practical experience in using standard Torres Strait Islander people in remote and regional techniques for assessing patients’ current mental or cog- areas have alarmingly high levels of psychiatric disorders. nitive state. As a result of these discussions, the PMHD Aboriginal and Torres Strait Islander people are subject was revised with a greater focus on depression, Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 3 of 7 anxiety and suicidal thoughts, plus teaching students medical training and experience increasingly complex general skills in mental health assessment; for example, patient encounters, it is expected they will appreciate practical techniques for interviewing and assessing pa- more and more the integral nature of psychological tients with disorders of mental health (techniques for medicine in medical practice. assigning diagnoses appropriately were a secondary con- PMHD approaches psychological medicine from a sideration). Thus, student discussions directly resulted in developmental perspective; which is in keeping with the PMHD subject being re-designed to include content the previous human development and behaviour not just more relevant to the mental health needs of the course, as development is the core theme of the sub- local region, but practical enough so that JCU medical ject. However, the subject was modified into PMHD students can practice and further develop patient- by further incorporating relevant and practical med- centred competencies associated with mental health ical perspectives for students to better appreciate the while on rural and remote community placements. value of psychological medicine in all settings, par- While all Year 2 JCU medical students undertake patient ticularly rural and remote medicine. history-taking and examinations during their mandatory 4- PMHD draws together the biological developmental un- week placement in a rural community, only half the student derpinnings with psychological development to promote cohort experiences the PMHD subject before their Year 2 the view of individual patients as a ‘bio-psycho-social’ en- placement. This allowed the present study to approximate tity. PMHD emphasises the psychological disturbances at the level of preparedness conferred to JCU medical stu- each stage of development, and its relation to developing dents from the PMHD subject in regards to mental health psychological disorder at different ages. There is explor- interviewing, history-taking and examinations. ation of how psychological health, illness and behaviour are closely related. Students are led to the logical conclu- Methods sion that an understanding of psychological medicine, in Study design combination with a strong therapeutic relationship be- This 2014–15 study of JCU MBBS students utilized a tween the doctor and the patient, is critical to achieving non-randomized controlled design to compare the pa- good patient outcomes. tient mental health experiences of 91 Year 2 students In addition to the theoretical underpinnings that ex- who went on rural placement before undertaking the plain how biological and psychological developmental PMHD subject, to 118 Year 2 students who went on problems can contribute to illness, there is also an em- rural placement after undertaking PMHD. This design phasis on developing practical skills in mental state ex- was possible due to the fortuitous timing of the compul- aminations (MSE), cognitive assessments, and learning sory 4-week rural placement in the broader Year 2 med- practical formulation methods to summarise each psy- ical curriculum. Half the student cohort completed their chological disturbance. Lastly, the PMHD course high- rural placement before the psychological medicine sub- lights the importance of caring for one’s own ject, and the other half completed the placement after psychological health in order to be able to function well due to logistical reasons. This serendipitously allowed as a doctor and student. the opportunity of a ‘natural’ experiment to evaluate the efficacy of the PMHD subject involving two equivalent Participants and data collection groups of students. Ethical approval for the study was All Year 2 medical students at JCU in 2014 were in- obtained from the James Cook University Human Ethics vited to complete a survey during their post-rural Committee (case number H3031). placement de-brief session held several weeks after returning from their placement. About half the Year 2 Description of the PMHD subject JCU medical student cohort undertake their 4-week Theaim of the PMHD courseistoeducatestudents rural placement in June (before receiving the PMHD around psychological medicine being an essential subject from July to October that year), while the cornerstone of medical practice. Arguably, all medical other half do their Year 2 placement in December or interactions between patients and doctors involve the January (after receiving the PMHD subject). Students patient’s understanding and psychological reaction to were informed of the project aims, and that comple- illness. Thus, psychological medicine could be consid- tion of the survey was voluntary. ered the tapestry upon which clinical medicine exists. The more medical students are introduced to psycho- Survey logical medicine in a practical and relevant way early As there are currently no validated surveys in the lit- in their undergraduate course, the more it will be erature to evaluate how well health students under- understood and integrated into their future patient take a mental health history-taking and examination encounters. As students progress through their of patients, the survey used in the present study was Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 4 of 7 developed from a focus group discussion with 5 Year and “Did any of the practical skills provided by the PMHD 3 students in the year previous (2013) to the data subject come in useful on your Year 2 placement?” collection phase. The focus group discussions deter- mined exactly how Year 3 students felt the recently Analysis and statistics re-designed PMHD subject had benefitted them on All data were coded numerically and entered into the their rural clinical placement they undertook at the computerized statistical package for social sciences, SPSS end of their Year 2, and how the PMHD course could Release 20 for Windows (IBM Corp, Release 2011; be improved. The discussion led to improvements be- http://www.spss.com). Bivariate analyses between stu- ing made to the PMHD subject to incorporate more dent clinical experiences on rural placement and content and competencies around interviewing mental whether students had undertaken the Year 2 clinical health patients, and around depression and anxiety. placement before or after the PMHD course were The discussion also led to the development of the content assessed using two-tailed, paired T-tests and chi-squared and wording for the evaluation tool. The evaluation tool tests, as appropriate (Table 1). Statistical tests were con- was then trialled on the Year 2 students later that year, sidered significant with p-values < 0.05. and several adjustments made to the wording of the sur- The variety of responses given to the 2 open-ended ques- vey questions for greater clarity. tions: ‘what information provided in PMHD was relevant to In mid-2014, the evaluation tool was initially given to the patient discussions?,a ’ nd ‘what practical skills provided students who did not receive the PMHD subject prior to in PMHD came in useful during your rural placement?’ their rural placement. The evaluation tool included 3 were later grouped ‘aposteriori’ based on the students’ fac- four-point Likert scale questions, 8 ‘yes/no’ answer ques- tual experiences on placement, using simple content ana- tions, and an open-ended question asking “Why did/didn’t lysis (displayed in Table 2). The content analysis of the you feel prepared for discussions with patients around open-ended questions was conducted by the author TW, mental health issues?” (see Table 1 for a complete list of and this analysis was checked by CRB for investigator tri- all survey questions and wording). The evaluation tool angulation; differences were resolved through discussion was also given at the beginning of 2015 to students who between the two authors. received the PMHD subject prior to their rural placement at the end of 2014. This evaluation tool also included a Results further 2 open-ended questions: “Was any information Description provided in the PMHD subject relevant to patient discus- A total of 209 JCU MBBS Year 2 students participated sions around mental health on your Year 2 placement?”, in the study from a possible 217 (response rate = 96%). Table 1 Year 2 rural clinical placement experiences of JCU MBBS student with patients experiencing mental health issues, PRE and POST the Year 2 Psychological Medicine and Human Development (PMHD) subject Question Completed Year 2 rural clinical Completed Year 2 rural clinical p-value placement PRE PMHD subject placement POST PMHD (n = 91) subject (n = 118) How confident were you that you could detect patients with a Mental 2.2 2.8 < 0.001 Health problem? (1 = ‘not at all’,2 = ‘a little’,3 = ‘quite’,4 = ‘very’) How comfortable were you discussing Mental Health issues with a 2.5 2.9 0.001 patient? (1 = ‘not at all’,2 = ‘a little’,3 = ‘quite’,4 = ‘very’) How well prepared were you for Mental Health discussions with 1.8 2.6 < 0.001 patients? (1 = ‘not at all’,2 = ‘a little’,3 = ‘quite’,4 = ‘very’) Did you sit in with a General Practitioner during consults? Yes – 79% Yes – 86% 0.219 Was the topic of Mental Health raised during the consult? Yes – 92% Yes – 94% 0.541 Did you feel the General Practitioner’s responses in the patient consult ‘Don’t know’ - 82% Don’t know – 3% < 0.001 appropriate? Did you get to talk to patients yourself? Yes – 88% Yes – 94% 0.120 Did you feel some patients had Mental Health issues? Yes – 73% Yes – 90% 0.002 Did you discuss Mental Health issues with patients? Yes – 31% Yes – 62% < 0.001 Was the knowledge provided in PMHD relevant to patient discussions n.a. Yes – 85% – around Mental Health on rural placement? Did any of the practical skills provided in PMHD come in useful on your n.a. Yes – 88% – Year 2 rural placement? Chi-square test (2-sided) or T-test (2-sided), as appropriate Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 5 of 7 Table 2 Psychological Medicine and Human Development (PMHD) lecture content and practical skills reported by Year 2 James Cook University medical students as ‘being useful’ on their 4-week rural clinical placement (data derived from open-ended question) Lecture content Number of students who reported this being a useful aspect of PMHD (including % of the 97 students whom responded to this question) 1) Assessing mental illness; including MSE, mini-MSE and ‘A SAD WISH’ mnemonic 49 (51%) 2) General information on mental health (‘all was relevant’) 20 (21%) 3) Depression, loss and grief 21 (22%) 4) Interviewing mental health patients; e.g., how to approach the topic, history-taking, 15 (15%) communication, talking to family 5) Anxiety 10 (10%) 6) Lifespan development in relation to youth mental health 10 (10%) 7) Personality disorders; e.g., borderline personality disorder 8 (8%) 8) Managing mental illness; e.g., intervention strategies, care plans, medications 7 (7%) 9) Suicide prevention 5 (5%) 10) Elder health; e.g., dementia 4 (4%) 11) Psychoses; e.g., schizophrenia 4 (4%) 12) PTSD 3 (3%) Practical skills Number of students whom reported this being a useful aspect of PMHD (including % of the 100 students whom responded to this question) 1) How to undertake a MSE or mini-MSE; including ‘A SAD WISH’ and other mnemonics 89 (89%) for interviewing patients with depression (appetite, sleep, affect, diurnal variation, weight, interests, suicidal thinking, hopelessness) 2) Interviewing skills 20 (20%) 3) How to identify patients with a mental illness 5 (5%) 4) Suicide awareness, talking about suicide, and assessing patients with suicidal thoughts 4 (4%) Of the 209 students, 173 (83%) sat in with a GP during a confident in being able to detect patients with a patient consultation; of these, 161 (93%) reported that mental health issue (p < 0.001); were more likely to the topic of the patient’s mental health was raised during report they believed some patients had mental health a patient consultation. One-hundred and ninety students issues (p = 0.002); and were more likely to volunteer (91%) were also given the opportunity by their supervis- an opinion on the appropriateness of their supervis- ing General Practitioner (GP) to interview patients inde- ing doctor’sresponse(p < 0.001), compared to JCU pendently, with 95 (49%) discussing a patient’s mental medical graduates who undertook their rural clinical health issue in some way. placement before PMHD in mid-2014. Of the 118 students who completed their rural place- ment at the end of year 2014 after undertaking PMHD, 100 (85%) reported that the knowledge provided in Content analyses PMHD was relevant to patient discussions around men- Table 2 categorizes the PMHD lecture content and tal health, and 88% reported that practical skills learnt in practical skills that Year 2 JCU medical students re- PMHD were useful during their rural placement. ported useful on their rural clinical placement. Over- all, 97 Year 2 students (82%) reported finding at Bivariate analysis least one aspect of the lecture content of PMHD to The bivariate analysis in Table 1 shows Year 2 JCU be useful; most commonly this was around assessing medical students who undertook their rural clinical mental illness (51%) and specific information on ‘de- placement at the end of 2014 after completing pression, loss and grief ’ (20%), while 21% reported PMHD: felt more comfortable discussing mental ‘all was relevant’. Similarly, 100 Year 2 students health issues with patients (p = 0.001); were more (85%) found at least one practical skill to be useful, likely to discuss mental health issues with patients with the most useful practical skills being ‘how to (p < 0.001); felt better prepared to discuss mental undertake a Mental State Exam (MSE) or mini-MSE’ health issues with a patient (p <0.001); felt more (89%), and ‘how to interview patients’ (20%). Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 6 of 7 For the open-ended question ‘why did/didn’tyou medicine and associated clinical skills in an integrated feel prepared for the patient discussions around systems-based fashion. PMHD now combines a relevant mental health?’, several student comments were taken chronological curriculum for understanding psychological verbatim from the surveys to illustrate why students development and health across the lifespan. Students are who had undertaken PMHD didn’t always feel pre- taught how to conduct a thorough mental state examin- pared for patient discussions around mental health, ation with regard to psychiatric conditions across the life- even though as a group they reported feeling signifi- span, and how to conduct a cognitive assessment using cantly better prepared than students who had not the mini-mental state. With this curriculum change, undertaken PMHD. Typical comments included: PMHD should now provide medical students with rele- vant and practical mental health knowledge and compe- “PHMD prepared me to handle certain patients with tencies for their extensive hospital and medical centre mental illnesses, but because it is a sensitive/daunting placements in Years 2, 4, 5 and 6. On these rural place- consultation, I felt only a little ready.” ments, it is almost certain the students will come into dir- ect contact with patients experiencing psychological distress, and/or be present in the room where a doctor “You know they have some very complex problems will model general skills in interviewing patients with psy- going on in their life and you don’t want to say chological distress as part of the general consult. Some- anything wrong. I feel very young and inexperienced”. times, the medical student will even be asked to undertake a mental health assessment and interview by themselves. Indeed, the content analyses shows 82% and 85% “The PMHD subject really helped. [But] I didn’t feel of the students who went on their Year 2 placement quite prepared as it was my first time experiencing after undertaking PMHD reported at least one aspect real life practise with the Mental State Exam.” of the lecture content and the practical sessions, re- spectively, came in useful when discussing mental health with patients experiencing psychological dis- “Had a 17 year old male who had come in for tress. In particular, students found the information gynecomastia but was very suicidal – I felt I wouldn’t on locally prevalent mental health conditions and have been equipped to talk to him as he was really practical experiences in the classroom around inter- intense”. viewing patients about these conditions and conduct- ing depression and anxiety assessment and mental stateexaminationstobeofmostuse. “There are a lot of things that can simply not be However, it is not expected that a single semester prepared for in theory, such as the physical subject in year two of an undergraduate medical interactions with patients, particularly in course would fully prepare students for detecting, schizophrenia cases”. diagnosing and treating disorders of mental health in medical practice. Indeed, this study found many stu- dents reporting they did not feel fully prepared for Discussion discussing mental health with patients experiencing This study demonstrates JCU medical students who psychological distress even after undertaking PMHD. undertook a psychological medicine course with lecture Some students found the topic too sensitive or sub- content on the mental health issues prevalent in rural ject material confronting (e.g., sexual abuse, refugees areas and practical experiences around discussing and with PTSD), while others were concerned about say- assessing these issues with patients, reported being sig- ing the wrong thing to either make the situation nificantly better prepared for interacting with patients worse for depressed or suicidal patients, or poten- having psychological distress than students who went on tially turn psychotic patients violent. their rural placement before undertaking the psycho- Australian medical students will regularly treat pa- logical medicine course. While it is not new that the tients with disorders of mental health in general practice medical students should be equipped to deal with disor- or on hospital wards because such disorders are com- ders of mental health, it is new that medical students are mon in Australian populations; especially rural and re- reporting that they are benefiting from early under- mote communities. Although often confronting, medical graduate exposure to practical and relevant mental students are able to grasp and appreciate the many as- health knowledge and competencies. pects of mental health in different settings if provided As with other streams of the medical curriculum at with the appropriate relevant and practical mixture of JCU, there has been an attempt to build psychological mental health knowledge and competencies. Rikard-Bell and Woolley BMC Medical Education (2018) 18:118 Page 7 of 7 It is also suggested that this novel methodology – align- manuscript; with special thanks and very fond memories of Maggie Grant for her assistance with the initial design of the PMHD module. ing formal teaching in a subject with an evaluation utiliz- ing a proximate student placement to provide useful Funding feedback on the curriculum content and assess the rele- No funding to support the conduct of the research project was received. vance of the material taught and improve the delivery of Availability of data and materials appropriate practical competencies – could be used to re- The datasets entered and analysed for the current study is available from the vise other content areas of a medical course to be more lo- corresponding author on reasonable request. cally relevant and practically focused, and then to evaluate Authors’ contributions the success of this revision. The individual contributions of authors include author CRB who conceptualized the study, developed the revised PMHD subject, entered the survey data, and was a major contributor in writing the manuscript, while Limitations author TW developed the survey, analyzed and interpreted the student data, While the nature of the JCU MBBS program is not and was a major contributor in writing the manuscript. Both authors read representative of all medical schools across Australia and approved the final manuscript. or the world, it is expected that there will be some Ethics approval and consent to participate commonality between PMHD and the teaching of Ethical approval for the study was obtained under the James Cook University psychological medicine in other medical courses. Human Ethics Committee (H3031). Students were informed about the study at time of data collection, and were made aware that participation in the Thus, the main limitation of the study is likely to be study, which involved completing a 2-page survey, was completely voluntary. that while the data collection method was developed The JCU Human Ethics Committee does not require students to sign a con- and tested for validity with Year 3 medical students, sent form when filling out surveys – survey completion is sufficient to show consent. it was not formally tested for reliability. In addition, it is uncertain whether the proportion Consent for publication of consults for students who went on their rural The authors give our consent to publish the manuscript. placement pre-PMHD subject are comparable to Competing interests those in the post-PMHD group; that is, whether the The authors declare that they have no competing interests. proportion of consults warranting some mental health query would have been the same. However, given the Publisher’sNote prevalence of patients presenting with mental health Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. issues in Australian rural practice [4, 5], the propor- tion is likely to be similar. Received: 4 November 2016 Accepted: 18 April 2018 Finally, while post-hoc analyses were undertaken that showed no differences in regards to gender and References end-of-year academic achievement between the 2 1. Boelen C, Woollard R. Social accountability: the extra leap to excellence for groups of medical students who went on placement educational institutions. Med Teacher. 2011;33(8):614–9. 2. Hays RB. A new medical school for regional Australia. Med J Aust. 2000; pre- versus post-PMHD course, it may be that the 172(8):362–3. second group(whichreceivedthe PMHD course) had 3. Palsdottir B, Neusy A, Reed G. 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Educ Med J. tients in the local region experiencing psychological 2014;6(1):e31–9. https://doi.org/10.5959/eimj.v6i1.225. distress, than are students whom are not provided 10. Pavlidou A. Pysch med in Bart’s: improving access and awareness. BMJ these experiences. Quality Improvement Reports. 2015;4. https://doi.org/10.1136/bmjquality. u206661.w2871. Accessed 25 Sept 2016. Acknowledgements 11. Wittchen H-U, Műhlig S, Beesdo K. Mental disorders in primary care. The authors wish to acknowledge the JCU medical graduates who Dialogues Clin Neurosci. 2003;5(2):115–28. PMCID: PMC3181625 participated in this study and to Tarun Sen Gupta for revision of the
BMC Medical Education – Springer Journals
Published: May 31, 2018
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