What can be done to improve medical students’ perceptions of their psychiatry clerkship? As Balon suggests, interventional research is needed to address what could make this experience a positive one (1). Multiple studies demonstrate improved satisfaction when students are taught via Active Learning (AL) techniques; therefore, integration of AL into clerkship curricula may be an excellent place to begin (2–9).

In an attempt to improve student satisfaction with a third-year psychiatry clerkship, the clerkship director (MM) introduced AL into the curriculum. In addition to assessing the impact of this intervention on student satisfaction and National Board of Medical Examiners (NBME) psychiatry subject examination scores, as has been done in previous investigations, we examined additional outcomes, including influence on sense of preparedness for the institutional-based Objective Structured Clinical Exam (OSCE) and changes in students’ professed interest in choosing psychiatry as a specialty (2–9). We anticipated that AL would improve student satisfaction and hoped to show that it would be successful in improving the other outcomes measured.

Sample

Medical students at Wayne State University School of Medicine rotate through one of seven clinical sites during their 1-month psychiatry clerkship, but together attend weekly educational seminars led by the clerkship director. These seminars include instruction regarding psychiatric diagnosis, the mental status examination (MSE), psychosocial treatment, and psychopharmacology. In 2008, students (N=108) learned solely by traditional lectures. In 2009, students (N=102) were given lectures on psychopharmacology only. In lieu of lectures related to diagnosis, the MSE and psychosocial treatment, AL techniques were used. In the AL seminars, students viewed video vignettes of patient interviews and then broke into small groups to formulate a Mental Status Examination and differential diagnosis. The clerkship director ended the seminar by eliciting discussion of these components, as well as psychosocial and pharmacologic treatment-planning.

Survey Instrument

In both years 2008 and 2009, upon completion of the clerkship, the NBME psychiatry subject examination, and the institution-based OSCE, students were asked to complete an anonymous IRB-approved questionnaire via an Internet survey tool. Completing the survey implied informed consent to participate in this study. Utilizing a Likert scale (1: Strongly Disagree, very unlikely or very unsatisfied; to 5: Strongly Agree, very likely or very satisfied) students were asked to rate the following statements: 1) I was prepared for the OSCE; 2) I was prepared for the NBME subject exam; 3) How satisfied were you with your psychiatry clerkship?; and 4) How likely is it that you will chose psychiatry as a specialty?

Analysis

Means and standard deviations (SDs) were calculated. Independent-samples t-tests were utilized to compare USMLE Step 1 scores (taken before the psychiatry clerkship), NBME psychiatry subject examination results, and responses to the survey (both completed after the clerkship). Analysis-of-variance models were used to compare the survey outcomes by clinical rotation site.

The only statistically significant result in the initial analysis was a feeling of better preparedness for the OSCE examination in those students exposed to AL (Table 1). Because experience during the month varied widely, depending on clinical site placement, we went on to examine responses by both site and year. We conducted a two-way ANOVA, with group and site as the two fixed factors. In this analysis, the AL group had an estimated higher mean score on Satisfaction (4.19) than the group who received the traditional curriculum ([3.83]; F[1.184]=6.29; p=0.013). No other outcome was affected by site placement.

NBME psychiatry subject examination performance and students’ professed interest in selecting psychiatry as a specialty did not differ by curriculum intervention, and, as stated above, did not depend on the clinical site where the student rotated.

Of note, the two groups of students’ USMLE Step 1 scores were compared, to examine academic differences between the two groups before the clerkship. There was no significant difference between groups (AL group mean: 216.20; traditional curriculum group mean: 216.42).

Although there have been concerns in the literature regarding decreased performance on standardized examinations when we veer from traditional curriculum approaches, this study found no significant change in NBME subject examination scores (10, 11). Investigators examining the use of AL in medical clerkships have found varying results regarding impact on NBME subject examination scores. Curtis et al. (2), Washington et al. (8), and Levine et al. (4) discovered significantly improved scores on the NBME pediatric, family medicine, and psychiatry examinations respectively. Of these three, only Curtis controlled for academic differences before comparing groups (2). Nalesnik et al. (6) and Wendelberger et al. (9) found no significant differences on the NBME subject examination in groups exposed to AL. Neither of these investigators controlled for academic differences before the clerkship. It is important to note that no study examining the use of AL in clerkship curricula has found a decrease in NBME subject exam performance (2–9). Additional well-controlled studies will be necessary to elucidate the impact of AL on this outcome. However, standardized examinations may not be the best barometers of learning. Supporters of AL argue that these types of exams do not assess the deeper learning promoted by such techniques (10).

Although the OSCE at our institution is not graded, it is possible that the sense of better preparation for this examination in the AL group indicates increased clinical acumen. The utilization of video vignettes demonstrating psychiatric interviews may have contributed to this finding.

Students in our study who received the AL intervention did not have an increased likelihood of professing interest in psychiatry as a specialty. Mean scores on this variable were quite low, regardless of curriculum (mean: 2.53, in 2008; mean: 2.55, in 2009). This outcome did not vary across clinical site. Given the fact that almost two-thirds of psychiatry residents rated their clerkship experience as the most important medical school influence in their specialty choice, this result is worrisome (12).

The finding that AL improves student satisfaction (after controlling for clinical site placement) is consistent with multiple studies examining the integration of this teaching method into clerkship curricula (2–9).

Limitations of this study include small sample size, the single site, lack of information regarding the demographics of each group (age, gender, ethnicity), and the fact that the students were educated in different academic years. Also, the survey instrument was not assessed for validity. Given the sense of increased preparedness for the institutional OSCE in the AL cohort, it would have been interesting to compare scores between groups on the USMLE Step II Clinical Skills examination. In conclusion, this study confirms that AL improves students’ satisfaction. Perceived preparation for the OSCE was also increased, which could be a contributor to increased satisfaction and reflect better clinical preparedness. NBME shelf-examination performance was not affected by AL, and professed interest in psychiatry as a specialty did not increase. Although further studies are necessary to clarify the connection between satisfaction with a clerkship experience and choice of specialty, satisfaction, in and of itself, is a valued outcome.

There are no sources of financial or material support for this paper, and it has never been publicly presented.