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Regular Article | March 01, 2002

Standards for Psychiatry Clerkship Directors

Thomas W. Kuhn, M.D.; Mitchell J.M. Cohen, M.D.; H. Jonathan Polan, M.D.; E. Cabrina Campbell, M.D.; Kathleen A. Clegg, M.D.; Amy C. Brodkey, M.D.

Academic Psychiatry 2002;26:31-37. 10.1176/appi.ap.26.1.31

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Clinical ClerkshipOrganization and Administration

Dr. Kuhn is at the Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI; Dr. Cohen, Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, PA; Dr. Polan, Department of Psychiatry, Weill Medical College of Cornell University, New York, NY; Dr. Campbell, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA; Dr. Clegg, Department of Psychiatry, Case Western Reserve University, Cleveland, OH; Dr. Brodkey, Department of Psychiatry, University of Pennsylvania, and Friends Hospital, Philadelphia, PA. Address correspondence to Dr. Kuhn, Department of Psychiatry, 3P Detroit Receiving Hospital, 4201 Antoine, Detroit, MI 48201.

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Abstract

The authors review the literature relevant to the position of Psychiatry Clerkship Director (PCD) and propose standards regarding the expectations for this position. The standards address qualifications, duties, and competencies in the areas of leadership, administration, education, mentoring, and scholarship, as well as the resources of time, administrative assistance, budget, and compensation required to carry out these duties. This paper has been endorsed by the Council of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), by the American Psychiatric Association's Committee on Medical Student Education, and by the Executive Committee of the American Association of Chairmen of Departments of Psychiatry.

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William Osler developed the first American clinical clerkship at Johns Hopkins in 1896. Unlike other U.S. medical schools of the time, Hopkins required medical students to have direct patient care responsibility (1). Flexner endorsed this as a standard for all medical schools (2). In order to allow for widespread implementation of this model, the position of clerkship director (CD) emerged. In recent years, at least seven national organizations devoted to medical student clerkships have developed (3). These organizations have joined together to form the Alliance for Clinical Education (ACE), with the mission of fostering collaboration across specialties to promote excellence in clinical education of medical students.

The value of the psychiatry clerkship in medical student education is widely recognized. All 126 U.S. allopathic medical schools require their students to complete a clinical clerkship in psychiatry (4). This clerkship has taken on increased importance as the clinical practice of medicine evolves. Studies have shown that 25% to 30% of patients in primary care settings have a diagnosable psychiatric disorder (5—7). Despite this, there is underrecognition of psychiatric conditions in the primary care setting (8,9). Even for those students not intending to pursue a primary care career, clinical training in psychiatry is a necessary part of a general medical education (10).

Historically, the primary mission of medical schools was education. In the post—World War II period, American medical schools evolved into large and highly complex institutions with multiple missions (11). Attempts to rationally allocate resources to support these missions have led to the concept of mission-based budgeting (12). This requires that faculty roles be clearly defined. The duties and responsibilities of the psychiatry clerkship director (PCD) have not previously been fully and uniformly characterized, although some efforts have been made. For example, a number of surveys of CDs' age, gender, academic rank, and time spent in various activities have been done (13—16). Pangaro proposed standards for proficiency and productivity of, as well as resources to be allocated to, CDs in internal medicine (17). Various aspects of the CD position have been addressed in the ACE/Association of American Medical Colleges (AAMC)—sponsored publication Handbook for Clerkship Directors and in a chapter on psychiatric clerkships in the Handbook of Psychiatric Education and Faculty Development (18,19).

The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) convened an ad hoc task force to develop this position paper on the expectations of and for the PCD. This paper was distributed to the ADMSEP membership for review and has been endorsed by the ADMSEP Council, by the American Psychiatric Association's Committee on Medical Student Education, and by the Executive Committee of the American Association of Chairmen of Departments of Psychiatry.

QUALIFICATIONS

The PCD should be a board-certified psychiatrist, unless, in exceptional cases, a department's most qualified clinician/educator is a nonphysician. He or she should have experience with clinical supervision and classroom instruction of medical students and should have abilities and an investment in teaching. In order to develop the administrative skills necessary to manage the clerkship, prior experience as a clerkship site coordinator, assistant clerkship director, or assistant director of medical student education is desirable.

It is important that the PCD develop familiarity with principles of instructional design, valid and reliable assessment, the curriculum priorities of the department and school, and national curriculum standards. Essential personal qualities include enthusiasm for the work, accessibility, ability to communicate clearly and convey feedback, and a passion for teaching. Because the PCD places demands on colleagues without direct influence on their compensation or other incentives, she or he must have interpersonal skills and intellectual authority as an educator in order to persuade faculty to teach.

Although many psychiatric educators currently do not conduct educational research, it is becoming increasingly expected that they will do so. Therefore, interest and skills in educational research methodologies are desirable. Knowledge of postgraduate programs can be very helpful in order to provide career counseling to medical students. These competencies may not all be present in a new PCD, and mentorship by the director of medical student education, chair, and education dean is essential in developing these skills.

DUTIES AND COMPETENCIES

The duties of the PCD can be classified into five domains: leadership, administration, education, advising/mentoring, and scholarship. These are summarized in Table 1.

Leadership

As defined by Kotter, leadership is the ability to develop a vision of the future, align people with that vision, and inspire them to make it happen despite obstacles (20). In concert with the chair and the medical student education committee, the PCD develops a vision for the clerkship, and the PCD is the key element in the realization of that vision. The people involved in actualizing this vision and who require inspiration from the PCD are diverse and include medical students, teaching faculty, the chair, departmental director of medical student education, CDs from other departments, the dean, and medical school committees.

The PCD has the additional challenge of presenting psychiatry to nonpsychiatric colleagues. All specialties are unique, but psychiatry is at particular risk of being misunderstood. Because our specialty has a rich but often confusing and divisive heritage of pluralism, the PCD, chair, and other departmental educators must develop and present a coherent view of the field (21). This includes educating faculty in other departments and administrators about the value of a psychiatric perspective to the practice of clinical medicine.

Administration

The PCD is responsible for a full-time clinical training experience for 50 to 250 medical students per year. The PCD organizes the schedules and clinical assignments of the students, coordinates these with departmental faculty and the dean's office, and monitors compliance with medical school policies (19). The PCD ensures that formative and summative evaluations are completed on all students, that grades are reported to the medical school, and that students at all training sites receive an equivalent educational experience that is consistent with clerkship goals. In collaboration with the medical student education committee and other departmental leaders, the PCD establishes standards for evaluating students, individual faculty, and sites, and conveys these to the students and faculty. These tasks require the PCD to manage personnel, budgets, and office space (22).

The PCD interacts with colleagues in the department, medical school, and affiliates on a regular basis. The administrative responsibilities of the PCD are substantial, but the administrative authority over faculty and residents is indirect, both at the medical school and at affiliated institutions. Having few resources of funding or space to distribute, the PCD exerts influence indirectly, through interpersonal skills, intellectual authority, and by providing feedback to the director of medical student education, chair, dean, and promotion and tenure committees.

Education

The PCD develops and delivers a set of clinical and didactic experiences based on local needs and resources as well as national standards such as the ADMSEP Educational Objectives for a Junior Psychiatry Clerkship (23,24). The PCD also develops and implements strategies to assess whether the students have achieved the stated objectives of the clerkship (25,26). In order to maintain credibility and contact with the faculty and trainees, the PCD should be a major teacher in the clerkship and other departmental teaching programs (19).

The PCD fosters the exchange of ideas, information, and innovation across and between levels of the training hierarchy, contributing to an atmosphere of intellectual curiosity and lifelong learning. She or he should encourage peer learning among students and among internal, affiliate, and external faculty. The PCD collaborates with the director of the preclinical psychiatric curriculum to provide continuity in curricular process and content. She or he also collaborates with the residency training director and other faculty to facilitate teaching and scholarship along the educational continuum, from faculty to students and residents to students (19,27). Interns, residents, and attendings have complementary roles in the clinical training of medical students, and all have a demonstrable effect on medical student learning (28,29).

Advising and Mentoring

Because the PCD's office is often a focal point for individual career counseling, advising, and mentoring of students and junior faculty, the PCD must be available and engender trust (30,31). For students interested in further psychiatric training, the PCD recommends electives, research experiences, and (for qualified candidates) psychiatry residencies. A broad knowledge of training programs and career options nationwide is useful. He or she prepares the students for the emotional reactions that may develop during the clerkship. The PCD identifies and counsels students with deficits of knowledge or skills, but should avoid diagnosing or treating these students or any student for which the PCD provides clinical supervision or summative evaluation (32).

Scholarship

Both the AAMC and the American Medical Association encourage educational research in medical schools (10). To ensure that the position of PCD is viewed as part of the academic enterprise of the department, it is advisable that the PCD engage in scholarly activity related to education. This may include presentation at professional meetings, publication (including abstracts and posters, books or book chapters, and peer-reviewed papers), and committee service in the medical school and relevant local and national organizations.

RESOURCES

The strong support of the chair is critical for the PCD to develop and maintain a high-quality educational program. This support should include access to the chair and regular meetings to discuss the clerkship and related medical school issues (18). There may be other levels of departmental educational leadership, including a director of medical student education and a vice-chair of education. If so, all of these individuals should work collaboratively.

Time Allocation

Current time allocations for clerkship directors in pediatrics, psychiatry, obstetrics and gynecology, and internal medicine have been studied (13—16). The results are summarized in Table 2. Although the time allocation for pediatric clerkship directors is quite low, they reported that more time would be preferable (16). Our analysis of the duties of the PCD makes the necessity for these allocations clear and has led us to recommend an allocation of 20% full-time equivalent (FTE) for clerkship administration, 25% FTE for direct teaching, and 10% FTE for educational research or other education-related scholarly work, for a total of 55% of time devoted to clerkship-related activities. The recommended time allocation may need to be adjusted at individual institutions to account for factors such as variation in class size and number of clerkship sites. This recommendation is consistent with that of the Association of Professors of Medicine that a minimum of 50% FTE be allotted to the position of CD if personal teaching and scholarly activity are expected (17). This time allocation is also consistent with the guidelines for mission-based budgeting published in Academic Medicine in 1999 (12). Under these guidelines, a clerkship director is allotted 20% time for clerkship administration, plus time for the direct teaching of students. (Scholarly activity is not accounted for in this model.) PCDs with additional medical student responsibilities, such as director of medical student education, require more protected time.

Administration

Phelan and Fincher recommend a full-time administrative assistant whose time is primarily assigned to the CD (22). Individual institutions may vary, but published guidelines have recommended that 75% to 100% of the administrative assistant's time be devoted to the psychiatry clerkship (19,30). Clerkships with multiple sites need additional administrative assistance for the site directors. Duties of the administrative assistant are outlined in Table 3.

The PCD should have access to a biostatistician and a master's- or Ph.D.-level educator who assists with curricular design, scoring and evaluation of examinations, analysis of course evaluation data, and educational research (22). These individuals may be dedicated to the department, or they may work out of the dean's office or the office of medical education to provide consultations to many departments.

The PCD and support staff require space, furniture, and office supplies and equipment, including computers with internet access, an office software package, a statistical package, and a reference manager (22).

Budget

The PCD should have access to, and be accountable for, a budget to support direct student costs, faculty development, clerkship administration, and awards for students and faculty (19,22). Direct student costs include printed materials, standardized patients, videotaped materials, computerized instructional materials, testing materials, and honoraria for outside teachers. PCD development is fostered by support for dues for relevant professional organizations and travel to critical meetings such as the annual meetings of ADMSEP and other educational organizations (27). The PCD also needs access to general and subspecialty psychiatry journals, as well as Academic Medicine, Academic Psychiatry, the Handbook of Psychiatric Education and Faculty Development, and the Handbook for Clerkship Directors (27). Development of other faculty is fostered by retreats, workshops, and other organizational meetings related to medical student education.

Compensation and Professional Development

Educational excellence is facilitated if the PCD, department chair, and medical school dean develop a system to acknowledge and compensate faculty for educational excellence. This system may include promotions, raises, travel, or budgetary support for new initiatives. In an era of increased fiscal accountability, schools of medicine must monitor productivity of faculty and staff and ensure that dollars allocated for education go to support effective educators and programs.

The professional development of the PCD is dependent on proper mentoring and supervision by the chair as well as by more senior educators, within the department or elsewhere (17,27). The new PCD should be provided with the opportunity to attend a new clerkship director's course and to receive additional training in educational design and research (17). Salary support for an individual PCD may come from several sources. For example, the PCD's teaching effort may be funded by the hospital, whereas the school of medicine may fund the administrative effort.

SUMMARY

Osler's clinical clerkship remains the cornerstone of medical student education, but the twentieth century brought many changes and challenges for medical education and the practice of clinical medicine. As we enter the twenty-first century, medical schools will need to reaffirm their commitment to medical student education and make corresponding changes in the academic culture.

Psychiatric disorders are very common and are often underrecognized in the primary care setting. Changes in the health care delivery system mandate that prospective generalists be given sound training and skills in recognizing and treating mental illness (33). It is therefore more important than ever that the duties of the Psychiatry Clerkship Director are clearly spelled out and that she or he is provided with sufficient resources to carry out those duties.

The position of PCD requires a minimum of 55% FTE if leadership, scholarly activity, mentoring and advising, and the development of innovative educational programs are desired. The PCD should be provided with an assistant, most or all of whose time is devoted to the clerkship. The PCD also needs access to adequate space, supplies, budget, and consultants in educational design, assessment, and research. To maintain high-quality medical student education, PCDs, their chairs, and deans must develop ways to acknowledge and compensate faculty for educational excellence. As in all areas of academic medicine, considerable change and evolution lie ahead for the role of PCD. In this context, it will be critical to preserve the core PCD missions of leadership, administration, education, mentoring, and scholarship.

ACKNOWLEDGMENTS

The authors thank Yolanda Pitts for her assistance in preparing and distributing this manuscript to the ADMSEP membership for their review, and Chris-Ellyn Johanson for reviewing the manuscript and providing editorial suggestions.

TABLE 1. Duties and competencies of the clerkship director

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TABLE 2. Time allocation of clerkship directors

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TABLE 3. Duties of the administrative assistant (clerkship coordinator)

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