CLINICAL REFLECTIONS
Medical education has traversed an evolving path over the past few decades. Dissatisfaction with static didactic lectures has given way to initiatives such as case-based or problem-based learning and similar “flipped classroom” teaching approaches, in essence making the learner a more active than passive participant in garnering new knowledge.1 Indeed, “active” learning approaches boost retention by 40%.2 Realizing that, modern medical educators often morph traditional Socratic questioning into the embedding of “audience response questions” (ARS) within formal presentations.1 With an average attention span of about 6-12 seconds (a range that is optimized in young adults)3 and a penchant for digital multi-tasking, millennials and Gen Zers are perceived as learning (or preferring to learn) mainly through small bytes of information. However, while some authors lament that classroom attention wanes after 10-15 minutes,4 studies suggest that active learning depends not so strictly on brevity of content so much as on how effectively an educator engages the listener.5
Anyone involved in residency education nowadays likely recognizes that the valuation of outstanding teaching skills has become the neglected stepchild of academia. Now more than ever, capturing and scaling the ingredients that make for compelling and impactful teaching for trainees is vital to our future. How to teach psychopharmacology with gusto was a focus of the recent annual meeting of the American Society of Clinical Psychopharmacology (ASCP), where one of us (SMS) presented ASCP’s inaugural Henry Nasrallah Award lectureship for Excellence in Clinical Psychopharmacology Education. That ASCP presentation, entitled “Teaching the Teachers of Psychopharmacology: Where Should the Focus Be, on the Content, on the Presenter, or on the Participant” suggested that the focus of great teaching must lie squarely and primarily on the participant; but, to accomplish that feat, the presenter and content must rise to the occasion together of meeting the learner where they are at, on their own terms, and make them care about the content.1 They must deftly move the learner’s motivation away from “Will this be on the Boards?” to “Will this be on my patient?” Or, even better, like a magician who irresistibly taps into the participant’s curiosity, make the participant want to know how something works.
How do master educators make content sizzle and entice? The answer may lie in classical conditioning. We all remember things more vividly when content is paired with highly emotional engagement. Captivating orators and immersive story-tellers tap into what might be called “limbic learning”—that is, imposing upon the listener an experience that engages relevant brain areas (amygdala, hippocampus, prefrontal cortex) that pair content with high affective valence. Limbic learning makes riveting experiences, literally, memorable. (Remember your wedding? Birth of a child? Match day?) Now, from the standpoint of learning theory, imagine the following twist on fear conditioning: in the aftermath of an aversive or threatening experience, trauma-laden content becomes a series of encoded memories thanks to engagement of fear circuitry, making for a torrent of learned or “overlearned” details that the posttraumatic stress disorder world identifies as reexperiencing and reliving. What if instead of pairing content with aroused fear circuitry (think of “pimping” on rounds as operant conditioning), it were instead paired with a highly positive affective valence state? It becomes subject to registration and recall with a greater degree of vivid fidelity and detail than if the same factual content-to-be-learned were paired with no emotionally-laden stimulus. By definition, nobody forgets the details of an experience that creates unforgettable memories.
What does this have to do with how psychiatry residents can best learn psychopharmacology? Everything. One of the greatest challenges facing modern educators of clinical psychopharmacology (as in virtually all other areas of medicine) involves devising clever ways to pair raw factual information (say, understanding drug mechanisms of action, or the potentially arid pharmacokinetic landscape of drug-drug interactions and metabolism) with high levels of intellectual and emotional engagement for participants. That task is not quite the same endeavor as hiding the vegetables in cheese sauce, but the notion of creating elevated palatability has some faint resemblance.
This brings us back to how the participant must be the real focus of education. In the world of pedagogy, Albert Mehrabian’s6 so-called “7-38-55 communication model” posits that actual words account only for about 7% of learning; while 38% comes from pace, inflection, and tone; and the remaining 55% derives from facial expression and body language. In clinical psychopharmacology education, the task of imparting retainable knowledge may therefore require some degree of ingenuity around immersive story-telling, or fostering a high attentional and curiosity state of limbic engagement within the learner.
But what about content? First, let’s differentiate conceptual from sheer factual content. If one wishes to understand an idea such as neuroplasticity, or the logistics of synaptic transmission, or the ramifications of an event like enzyme inhibition or competitive receptor binding, it helps to explain in concrete terms the jobs of key players in a given system. Metaphor and anthropomorphism can help. For instance: “Imagine neurotransmitter particles traversing a synaptic cleft and binding to postsynaptic receptors like boats in the water that then either purposefully or indiscriminately land at one dock versus another. That explains pharmacodynamic efficacy and adverse effects, respectively. Now, shut down the means of reentry to the (presynaptic) point of origin—say, the serotonin or dopamine transporter—by inhibiting reuptake (imagine a Coast Guard vessel blocking the reentry port). With no place else to go, the messenger armada is now forced to make extra trips back and forth across the harbor, effectively increasing the efficiency of transmission by doing overtime work. Bonus points if the armada happens to land at preferred/highly desirable docking sites on the postsynaptic side (say, in the case of serotonin, the 5HT1A or 5HT7 receptors, rather than wreaking collateral damage by agonizing their way into undesirable, adverse-effect laden destinations such as 5HT3 (nausea city) or 5HT2A (agitation and sexual dysfunction city)”.
Go Back, Jack, Do It Again
Repetition is an enormously useful hack to reinforce registration and memory consolidation, as learners may find themselves sifting through a barrage of content, trying to discern varying degrees of relevance, while attempting to develop a coherent narrative to make sense of a potentially dense concept. This all works far better when the participant cares about the content and has reason to—not because they will simply be accountable for it, but because they harbor a sense of investment in possessing and using or wielding their knowledge. Let us here consider 4 relevant tenets to adult learning1:
- Adults do not want answers to questions they have not asked
- Adults do not argue with their own data*
- Learning has not taken place until behavior has changed
- Adults will increase their behavior after 1 exposure to materials if they are already doing that behavior, but it takes 3 exposures to get them to do a new behavior they are not already doing
* Beware the Dunning-Kruger effect, a construct from social psychology which describes instances in which people may fail to recognize when they do not understand something, but insist that they do, cling to wrong information, and resist efforts to correct their misperceptions.
Follow the age-old axiom of “say what you’re going to say, say it, and then say what you said.” Do it slightly differently each time, and preferably with increasing levels of associative limbic cues (humor? whimsy? note any paradoxes or traps for getting confused the first time around?). It helps simply to flag “this is the really important part, so let me say it again.” Or better yet, “this part can be confusing so let me try saying it a different way.” Humility can go far (“it took me umpteen iterations to understand where and how inhibiting an inhibitor increases neurotransmission so let’s look at GABA-glutamate interactions from another angle and tell me when you get it”). And then, best of all, “let’s see if someone can now explain this back to me.” Or, “how would you explain this to a junior trainee?” The latter approach almost reflects a kind of Rogerian active listening process, where the learner’s job is to make sure that they have correctly comprehended what they have heard, while the educator’s role is to convey salient information as clearly as possible. Think of psychotherapy patients whose narratives are more coherent than disjointed, then ask yourself which type of patient arouses more engagement and fosters a more collaborative understanding process with the clinician.
A learning model that has come to be known as the 4 stages of conscious competence (often attributed to De Phillips et al7) identifies successive stages in which a learner becomes increasingly aware of the lacunae in their knowledge base, experientially gains progressive mastery over those deficits, and ultimately develops a kind of effortless expertise through iterative learning. Figure 1 presents a modified version of this conceptualization highlighting the role of the educator as facilitator.
Figure 1. The 4 Stage Model of Conscious Competence
As shown in Figure 1, the “unconscious incompetent” is the initially ignorantly-blissful learner-to-be who knows not what they do or do not yet know. They occupy the intellectually virginal state upon which the educator makes their first pass of pointing out the salient problems and arouses interest and curiosity in the participant. (“Bet you did not know it was possible to saw somebody in a box in half. Wanna see it?”). Intrigued, the conscious incompetent is brought to realize the salient problems or phenomena relevant to their situation. (“How did you do that trick?”) No really meaningful learning can occur until the participant’s curiosity has been piqued and they are hooked. The conscious competent then tries to replicate what they think they saw. While natural skills certainly can help with this, it falls to the master educator to help move the participant down the field and over the goal line by equipping them with accurate factual knowledge (“Want me to teach you how to saw the lady in half?”) The master educator poses the issues with clarity; iterates and repeats; then repeats some more, from a different vantage point; engages limbic learning; then, repeats. This is perhaps a protracted version of “watch one, do one, teach one” with a little more pizzazz.
Repetition converts declarative memory (where you have to say out loud in your head what you are doing every step of the way; think of when you were first learning how to drive a car) to procedural memory (where you no longer have to consciously do all that; so, eventually, with enough practice, just about anyone can drive a car without having to think about how to do it; or play a musical instrument; or actively translate from one language to another). As is the case for anyone aspiring to become a virtuoso at anything, iteration eventually can produce that state of unconscious competence.
Figure 2. The Learning Pyramid
Now, let’s consider a kind of hierarchy of learning and memory as applied to teaching techniques, the so-called classical learning pyramid, as illustrated in Figure 2. Developed by the National Training Laboratories in Betel, Maine, this model identifies passive attendance at a lecture as the weakest form of learning and promotion of retaining knowledge, while imposing the task of learners actively teaching others is by far the strongest. Note the points of increasing levels of participants’ active engagement along the way.
Imparting memorable content can benefit from the use of metaphor (“imagine the D3 receptors in your reward circuitry drenched in dopamine binding by the partial agonist on this list with the strongest binding affinity”), or posing mechanistic questions as engineering challenges (“if you wanted to leverage anxiety through serotonergic circuitry, what would happen if you downregulated presynaptic 5HT1A autoreceptors and agonized postsynaptic versions of that same receptor?”).
What about dry factual content? In some ways, it can be easiest for both educator and learner to identify such details for what they are by acknowledging when a list of names needs to simply be memorized or paired with a function (eg, “here are the names of all the known serotonin receptors, their locations, and what they do. Remember them the way you remember the names of players on a sports team and associate the name with their function.”) Learners and educators alike appreciate such frank acknowledgments, and more pragmatically, knowing how and where to go find codified information in up-to-date fashion (eg, “Nobody can ever remember all the CYP450 substrates and inducers and inhibitors, but that is why the Flockart Tables website exists8”).
Resources for Education and Educating Educators
Apart from the art of pedagogy, a strong knowledge base for factual content is a cornerstone for understanding clinical psychopharmacology. New drugs emerge, new mechanisms of action become identified, nuanced information arises about drug-drug interactions, dissociation constants need interpretation, special populations need special considerations, dosing logistics need explaining, and basic principles sometimes just need rote memorization and/or comprehension (eg, What is zero vs first order kinetics? Tertiary vs secondary amine tricyclics differ how? What does p-glycoprotein do?). The ASCP has spent several years developing an all-new soft-ware based, expert-delivered, artificial intelligence-informed next-generation model comprehensive curriculum keyed to helping educators impart psychopharmacology content across successive years of residency education. More information about the ASCP Next Generation Model Psychopharmacology Curriculum can be found at www.edyou.com/ascp.
Concluding Thoughts
Masterful education in clinical psychopharmacology is participant-focused, but to make it so means serving up irresistibly-engaging content through clear and irresistibly-engaging form. The key person at a 3-star Michelin restaurant has to be the consumer of the meal; the chef de cuisine is really only as good as the consumer thinks they are for purposes of creating a satisfying experience that will make people want to come back for more. It may be a big ask to assume that actual content is clear, unambiguous, and follows the arc of a lucid narrative story line, but in a way those raw ingredients are just the starting point, rather than the end point, for successful learning to occur. Learning clinical psychopharmacology, like any subject, must be fun. It must tap into the neural circuitry of imaginative play in the learner. When mixed with clear and accurate factual information, educators can produce the magical combination of effective teaching that will be memorable, indelible, and practicable.
Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology. Dr Stahl is an internationally recognized clinician, researcher and teacher in psychiatry with subspecialty expertise in psychopharmacology. He is currently a professor at the University of California, San Diego, and serves as Honorary Fellow in psychiatry department at the University of Cambridge.
References
1. Stahl SM, Davis RL. Best Practices for Medical Educators, 2nd Edition. Cambridge University Press; 2011
2. Deslauriers L, McCarty LS, Miller K, et al. Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proc Natl Acad Sci. 2019;116(39):19251-19257.
3. Simon AJ, Gallen CL, Ziegler DA, et al. Quantifying attention span across the lifespan. Front Cognit. 2023;2:1207428.
4. Hartley J, Davies IK. Note-taking: a critical review. Prog Learn Educ Tech. 1978;15:207-224.
5. Bradbury NA. Attention span during lectures: 8 seconds, 10 minutes, or more?Adv Physiol Educ. 2016;40:509-513.
6. Mehrabian A. Silent Messages. Wadsworth Publishing Co; 1981.
7. De Phillips FA, Berliner WM, Cribbin JJ. Meaning of Learning and Knowledge: Management of Training Programs. Richard B. Irwin; 1960.
8. Flockhart DA, Thacker D, McDonald C, et al. The Flockhart Cytochrome P450 Drug-Drug Interaction Table. Division of Clinical Pharmacology, Indiana University School of Medicine Updated 2021. Accessed June 11, 2025. https://drug-interactions.medicine.iu.edu
