The recruitment of child and adolescent psychiatrists is a physician-workforce matter that has been noted across the globe (1—5). The Psychiatry clerkship during undergraduate medical education has been identified as an important opportunity for implementation of Child and Adolescent Psychiatry (CAP) educational experiences, to address CAP's medical education and recruitment mandates (6—10). Such experiences have often been delivered as seminar-based and patient-based experiences, with surprisingly consistent effect. The literature examining the influence of these activities uniformly reports positive impacts on medical students' attitudes, interest, and career considerations regarding CAP subsequent to CAP clerkship experiences, even with as brief an educational intervention as a single 3-hour seminar (11—15). These studies did not, however, evaluate longer-term outcomes, such as residency matches relevant to eventual CAP practice, including CAP, psychiatry, and pediatrics. Pediatrics is relevant because knowledge of CAP is an important aspect of pediatric practice; some clerks expressed interest in CAP clerkships as a means to broaden their education regarding pediatric emotional and behavioral problems. Another limitation of this literature is that students' a priori attitudes and interest regarding CAP were not accounted for across these studies. Kaplan and Lake (11) and Szajnberg (12) did not use a pre—post study design, and the high-exposure CAP clerkship group in the Malloy et al. (14) study was a self-selected group. These limitations render it difficult to discern the mechanism(s) underlying the positive impacts reported.
As a result, questions remain unanswered: Is exposure to a CAP clerkship sufficient to facilitate choice of a CAP career? Are students inclined toward CAP inevitably likely to have their interest grow over the course of regular medical school experiences? Or, does one require a priori interest and a CAP clerkship to influence the rate at which students consider CAP as a career? These are important questions because if the apparently effective CAP educational strategies reported in the literature (11—15) do not translate into greater rates of students' pursuing a career in CAP, then one must be concerned that these educational recruitment efforts are being wasted and that new, possibly more effective, recruitment opportunities are not being developed. The same can be said if it is the case that the subset of students with an interest in CAP will grow in that interest over time and pursue a career in CAP no matter what educational recruitment interventions are available. The goal of our current study is to begin to address these significant limitations and facilitate further understanding of the recruitment potential of positive CAP clerkship experiences.
To do so, we studied a new CAP clerkship rotation that was implemented within the Psychiatry clerkship at the Michael DeGroote School of Medicine at McMaster University. To address the goal of ensuring that the positive influences reported in the relevant literature are not representative of a self-fulfilling prophecy (i.e., that a priori interest in a CAP clerkship is sufficient to create career interest in CAP) and tease apart the influences of interest and intervention, we will examine three groups of clerks: 1) those who expressed an interest in a CAP clerkship rotation and were enrolled in a CAP clerkship rotation; 2) those who expressed an interest in a CAP clerkship rotation but were not enrolled, and 3) those who did not express an interest in a CAP clerkship rotation. To address the goal of determining whether or not any beneficial effects of interest or intervention are likely to have an influence on recruitment efforts, thus looking beyond the short-term measures typically used in this literature, we will examine the pattern of clerks' residency matches.
In 2005, the Division of Child and Adolescent Psychiatry at McMaster University redefined CAP clerkship teaching goals in terms of its educational and recruitment tasks. The McMaster Division of CAP has a small faculty teaching cadre and, as a result, to support the Division's research and educational goals, it was necessary to concentrate these limited teaching resources within the Psychiatry clerkship by means of a new CAP clerkship rotation for only those clerks electing to participate. We believed that CAP recruitment was a significant national issue, warranting focused research and, with this selective CAP rotation, we could evaluate a specific recruitment model implemented with limited teaching resources. This CAP rotation matched CAP teachers with clerks interested in a CAP rotation, rather than teaching as part of the general pool of psychiatric clinical teachers. We hypothesized that this CAP rotation would enhance recruitment into CAP by emphasizing clinical case-supervision around CAP problems by CAP teachers, a key recruitment strategy identified by Szajnberg (12, 13) and by differentiating CAP as a distinct specialty within Psychiatry, which has been identified as a strategy facilitative of CAP recruitment (16).
The Psychiatry clerkship at McMaster University is a 6-week rotation. All clerks are assigned a faculty supervisor and complete clinical placements from a wide range of Psychiatry specialties within outpatient, inpatient, and community sites. Clerks have an on-call experience that is completed in a single general hospital-based psychiatric emergency service that assesses children, adolescents, and, mostly, adults with psychiatric conditions and emergencies. All clerks, irrespective of CAP clerkship interest, participated in this on-call experience. Similarly, all clerks had a centralized academic teaching day in Psychiatry during which grand rounds, large-group teaching sessions, seminars, and Problem-Based Learning (PBL) tutorials are conducted in a range of general adult Psychiatry topics. During the PBL tutorials, clerks may independently identify child and adolescent psychiatric learning objectives. The departmental academic teaching day was not modified as part of this CAP educational intervention.
As part of the administrative process leading up to the Psychiatry clerkship, students complete a Psychiatry assignment form. Students receive information necessary for completion of this form at an M.D. Program clerkship-information event, at which faculty from all medical and surgical specialties provide information regarding their respective clerkships. For the Psychiatry clerkship, this form enables clerks to choose from a number of clerkship placements, including CAP. For instance, placements in Schizophrenia, Addictions, Women's Health, and other programs are included on this form and were available for clerk placement during their Psychiatry clerkship.
For the purpose of this study, clerks' interest in a CAP clerkship rotation was defined as their request for a CAP clerkship rotation using this assignment form or interest in a CAP clerkship rotation expressed via telephone/e-mail contact with the administrative assistant of the Director of Psychiatric Undergraduate Education (MDH). Among those who expressed an interest, clerks were assigned to a CAP clerkship placement by this administrative assistant until all available CAP placements were filled. The administrative intent was to maximize CAP assignments for clerks interested in CAP, but the vagaries of CAP faculty availability and clerk CAP interest across clerkship rotations dictated the actual number of successful matches. Those who could not be placed in CAP despite expressing an interest and those who did not express an interest in CAP were assigned to non-CAP Psychiatry faculty and completed placements in other areas of the Psychiatry department.
Consistent with this new CAP clerkship model, clerks who received a CAP rotation assignment were assigned to one CAP faculty teacher and participated in multidisciplinary CAP/Child and Adolescent mental health outpatient clinics, which were either community- or hospital-based. CAP clerks participated in seminars and rounds specific to these CAP clinics. The CAP rotation was a blended rotation with Adult Psychiatry, with clerks spending one-half of their clinical rotation (2 days per week) within CAP and the other half (2 days per week) within Adult Psychiatry, and 1 day each week spent within the departmental academic teaching day as described. CAP-assigned clerks also had the option to attend a lunch (once per rotation) with the CAP Academic Chair (PS) to discuss CAP as a career. Clerks not assigned to a CAP rotation may have had some CAP experiences via their on-call experience (as described) and, for those clerks assigned to an Adult Psychiatry inpatient unit, there may have been some CAP experiences with adolescents with psychiatric conditions admitted for treatment. CAP experiences of these types were not documented for this study.
The clerks of the 2005—2007 graduating classes of McMaster University's undergraduate M.D. Program were studied. The McMaster M.D. Program is a 3-year, Problem-Based Learning (PBL) program. Clerks were categorized into three groups: 1) clerks interested in a CAP clerkship rotation and matched to a CAP rotation; 2) clerks interested in a CAP clerkship rotation but not matched to a CAP rotation; and 3) clerks not interested in a CAP clerkship rotation and not matched to a CAP rotation. This study received ethical approval from the Hamilton Health Sciences Research Ethics Board. Participants' informed consent was not deemed necessary because 1) study data were routinely collected by the M.D. Program; and 2) data were collected post-graduation and without risk to participants' educational standing.
The recruitment mandate was evaluated by means of residency matches to the various specialties achieved through the Canadian Resident Matching Service (CaRMS). CaRMS is a national service by which entry into postgraduate medicine is coordinated across Canada. The CaRMS match results are completed during the spring of each academic year and provide the best indication of whether or not clerk interest in a CAP clerkship rotation may translate into longer-term CAP career intent. For our study, the two CaRMS residency matches of Psychiatry and Pediatrics were highlighted among the total range of matches. Psychiatry was highlighted because it is the first postgraduate step in the career pathway to CAP residency training. In Canada, direct CAP residency matches post-medical school graduation do not exist, necessitating that those clerks interested in a CAP career to first match to Psychiatry. Pediatrics was highlighted because clerks interested in Pediatrics may select a CAP clerkship rotation in order to broaden their education in pediatric emotional and behavioral problems. Furthermore, substantial overlap across CAP and Pediatric career paths has been reported (4, 5, 12, 13, 17—19). The interest of some trainees in developmental inquiry, which is fundamental to both specialties, may contribute to these overlapping career paths (4).
Descriptive statistics were used, and chi-squared tests performed to compare the proportion of clerks matching to Psychiatry and Pediatrics residencies among the three clerkship groups.
The total number of medical school graduates across the classes of 2005—2007 was 412, with CaRMS data available for 411. However, 21 were excluded from analysis because administrative issues affected their CAP interest status. For instance, to maintain full clerkship assignments for each 6 week rotation, some clerks without expressed interest in a CAP rotation had to be administratively assigned to a CAP rotation. Of the remaining 390 graduates, 118 (30.3%) were male. Fifty-one clerks (13.1%) expressed an interest in a CAP rotation and were matched to a CAP rotation; 42 (10.8%) expressed similar interest, but were not matched; and the remaining 297 (76.1%) did not express an interest in a CAP rotation.
Canadian Resident Matching Service (CaRMS) Matches
To determine whether or not expression of interest in a CAP rotation and/or being matched to a CAP rotation influenced the rate at which clerks matched to Psychiatry or Pediatrics, we used chi-squared analyses. Table 1 illustrates the number (and percentage) of clerks who matched to Psychiatry, Pediatrics, or another specialty. Chi-square analyses revealed the proportion of clerks who matched to Psychiatry and Pediatrics to be significantly different across the three CAP interest groups (χ2=22.8; p<0.001). Comparing just those who expressed an interest in a CAP rotation and were matched to a CAP rotation versus those who expressed an interest in a CAP rotation but were not matched revealed that the proportion of these two groups who entered Psychiatry and Pediatrics was not significantly different (χ2=1.0; p>0.6) although the proportion of each was statistically different from that of the third, non-CAP-interest, group (χ2>8.0; p<0.01, in both instances). For clerks assigned to the CAP rotation pre-CaRMS application, their matches to Psychiatry or Pediatrics (34/53; 13.4%) were equally as likely as for those clerks assigned post-CaRMS application (3/38; 7.9%); χ2=0.92; NS.
TABLE 1.Number (and Proportion) of Clerks Matching to Psychiatry, Pediatrics, and Other Specialty in the Classes of 2005-2007 as a Function of Expressed Interest in a CAP Clerkship Rotation and Participation in a CAP Clerkship Rotation
CAP recruitment is an issue of international importance. In an effort to further understand the recruitment potential of CAP clerkship experiences, we have evaluated the differential impact of clerks' interest and participation in a CAP rotation on their Psychiatry and Pediatrics residency matches. CAP clerkship interest, and not participation, was associated with Psychiatry and Pediatrics residency matches. We identified two clerkship interest subgroups of recruitment and educational importance to CAP. For those clerks heading toward a Psychiatry residency, a CAP rotation represents a CAP recruitment opportunity. For those clerks heading toward a Pediatrics residency, a CAP rotation represents an educational opportunity to influence clerks' knowledge, skills, and attitudes and future practice regarding CAP conditions. Our study reports that CaRMS matches to Psychiatry and Pediatrics were greater in those clerks who expressed interest in a CAP rotation relative to those who did not, regardless of whether that interest was supported through assignment to a CAP rotation. This suggests that expression of interest is the more important variable. The lack of a CAP rotation participatory impact upon residency matches, although disappointing, suggests that CAP recruitment strategies should involve focusing on pre-assignment identification of a CAP clerkship interest group.
Our study finding stands in contrast with other CAP clerkship studies that have reported positive impacts associated with participation in CAP clerkship experiences (11—15). This discrepancy may be reflective of these previous studies not adequately attempting to tease apart the influence of interest versus intervention, or it may be reflective of the different time-frames represented by the outcomes measured across these studies. That is, the positive outcomes associated with CAP clerkship experiences reported in previous work were collected immediately post-clerkship, whereas we report an outcome of longer-term importance in an attempt to determine whether any immediate benefit translates into actual increases in the rate at which clerks enter psychiatry and pediatrics residencies.
As with any naturalistic observational study, there are limitations that require discussion. This study's CAP interest variable was a coarse measure and constituted simply enumerating clerks with interest in a CAP clerkship rotation. This variable left many questions unanswered regarding the nature of this interest. In particular, we presume factors other than interest in a career in CAP, Psychiatry, or Pediatrics may have influenced the decisions about which Psychiatry rotation clerks preferred. Despite that presumption, expression of interest appears to have been related to specialty choice. The study's CaRMS outcome measure was also coarse for Psychiatry and Pediatrics matches not CAP matches. We did not identify those clerks matching to Psychiatry who wished to eventually practice CAP, nor those clerks matching to Pediatrics with a specific practice interest in CAP concerns. Although this study has advanced CAP recruitment research to the career path juncture of residency matches, a next step would be to undertake a follow-up study of this cohort. The CAP clerkship rotation was a blended rotation with Adult Psychiatry, and the lack of participatory impact may have therefore been related to the lack of sufficient CAP exposure. Further complicating this CAP exposure effect was the possibility of some CAP exposure for those clerks assigned to Adult Psychiatry inpatient rotations or for all clerks during on-call shifts.
Future research regarding CAP recruitment strategies should better define the nature of clerks' CAP interest, including the comparative strength of early-career interests across CAP, Psychiatry, and Pediatrics. This study did not evaluate the residency-match impact of a CAP rotation on clerks without a priori interest in a CAP rotation. This would be an interesting future study and would require random assignment of clerks with and without a priori CAP interest across Adult Psychiatry and CAP clerkship rotations.
The finding that clerks' interest in a CAP clerkship-rotation is significantly associated with Psychiatry and Pediatrics residency matches provides evidence in support of early portal-of-entry strategies, such as the Triple Board Program for those medical school graduates interested in combined CAP, Psychiatry, and Pediatric careers (19, 20). In general, early portal-of-entry residency programs with assignment immediately after medical school graduation may serve as the most effective CAP recruitment strategies because they enable CAP to provide for those clerks expressing early career interest an immediate residency assignment tailored to their career interests (20). In Canada, with the recent Royal College of Physicians and Surgeons of Canada designation of Child and Adolescent Psychiatry as a board-certified subspecialty of Psychiatry, consideration of the adoption of early portal-of-entry recruitment strategies would appear warranted.
At the time of submission, the authors reported no competing interests.