Medical educators increasingly recognize student-run clinics as valuable contributors to medical education (1). Over half of medical schools in the United States now have at least one student-run clinic in operation. These clinics typically provide low-cost primary care, under faculty supervision, to uninsured patients. Student-participants can gain clinical experience in primary care often long before seeing their first patients in the formal curriculum.

This model may provide new opportunities for psychiatric education. Pre-clinical didactics and inpatient clinical experiences traditionally dominate the medical school curriculum, leading to an emphasis on severe psychopathology and acute psychiatric illness (2). This approach may not adequately expose students to the more common psychopathology found, and often managed, in primary care (3). Inadequate training likely contributes to the prevalence of physicians who fail to diagnose and treat common mental illnesses, such as depression (4).

These shortcomings have prompted efforts to reorient medical-student education toward the psychiatric disorders prevalent in general practice (4, 5). However, limited resource- and time-allocation may limit the feasibility of such efforts (6, 7). Also, patients and clinicians often object to direct student involvement in outpatient psychiatry practice because of privacy and confidentiality concerns (5), whereas student involvement is the accepted norm at student-run clinics.

This study explores the potential educational impact of a novel, student-run behavioral health program focused on depressive disorders by means of chart review and student self-report questionnaire.

The behavioral health program described here was implemented at Columbia Medical Student Outreach, an inner-city, student-run clinic affiliated with Columbia University and NewYork-Presbyterian Hospital. One-quarter of all medical students at Columbia University volunteer in this clinic at some point. This clinic is similar to many others across the country in its model of multidisciplinary collaboration between medical, nursing, and social work students, under the supervision of family and internal medicine faculty (1). Medical students organize 4–5 clinics each month and work in teams to care for 3–10 patients per clinic.

As part of the new behavioral health program, all medical-student volunteers were instructed on depressive-disorder screening and diagnosis. Students were encouraged to administer the Patient Health Questionnaire-9 (PHQ–9) at all appointments (8). Screening results were discussed with supervising faculty in order to formulate diagnoses and treatment plans.

A rotating team of volunteer psychiatry faculty provided additional supervision in monthly consultation sessions. Patients found to have depressive disorders appropriate for ongoing treatment within the clinic received an appointment to the next psychiatry-consultation session. Each patient was paired with an interested third- or fourth-year medical student, who could see the patient regularly for at least 6 months so as to allow personal care continuity. First- and second-year medical students joined these senior medical students for patient interviews on a rotating basis, thereby allowing wider participation in the psychiatry-supervised clinics.

A retrospective chart review extracted data on the frequency of depression screening, as well as the frequency of major depressive disorder (MDD) diagnoses and treatment offers during the 6 months before and after program implementation. The review included all patients with at least one regular primary-care appointment during this 1-year period. Each author reviewed all chart notes independently, with discrepancies resolved by the physician supervisor of the clinic. For the purpose of this study, depression-screening included both “formal” screening with a recognized instrument, such as the PHQ–9, and “informal” screening, as defined by specific notation of questions related to depression in the chart, but without mention of any instrument. MDD diagnoses were those noted after patient assessment and review by supervising physicians. An offer of treatment for MDD was defined by Practice Guidelines of the American Psychiatric Association (9). Fisher’s exact test compared data collected from before and after program implementation. All tests were two-tailed, with significance set at p≤0.05.

All medical students who volunteered during a 6-month period after program implementation received a self-report questionnaire. The questionnaire was developed using previous student feedback and literature review. It included a series of statements rated on a 4-point Likert scale (1: Strongly Disagree to 4: Strongly Agree), with results reported dichotomously (Agree or Disagree). Students received the questionnaire electronically, along with a study description and consent form. The Columbia University Institutional Review Board approved this study, and all study subjects consented to participate.

Patient Data

Figure 1 summarizes the frequency of depression screening, as well as the frequency of major depressive disorder (MDD) diagnoses and treatment offers during the 6 months before and after program implementation. The screening rate increased significantly (p<0.0001), from 13% of patients (N=9/71) to 80% (N=74/93). Before program implementation, most patients received informal screening (89%; N=8/9), whereas, afterward, all screened patients received the PHQ–9 (N=74/74). Diagnoses of MDD increased from 7% (N=5/71) to 13% (N=12/93), and the number of patients offered treatment increased from 6% (N=4/71) to 12% (N=11/93). However, these last two results did not reach the level of statistically significant changes for either diagnosis or treatment offered.

Student Questionnaire

Of the 108 medical students involved in patient care during a 6-month period after program implementation, 71 (66%) responded to the questionnaire. Eight (7%) of these responders indicated non-participation in screening and therefore did not complete the questionnaire.

Of the 63 questionnaire completers, 17 (27%) were first-year medical students; 16 (25%) were second-year; 14 (22%) were third-year; and 16 (25%) were fourth-year. In terms of career interest, 6 (10%) indicated intent to pursue a career in psychiatry; 27 (43%) indicated no intent; and 30 (48%) were undecided.

On the questionnaire, students endorsed many educational benefits of the depression screening and assessment program, including reinforcement of DSM-IV diagnostic definitions (97%), increased consideration of biopsychosocial factors (89%), greater confidence in asking behavioral health-related questions (77%), and normalization of the psychiatric history (89%). However, 55% of student disagreed with the statement that PHQ–9 depression screening “encouraged consideration of the patient less as a symptom or illness and more as a person.” Most students reported that their clinic experience would lead to greater appreciation of behavioral health in future clerkships (92%) and increased respect for the role of behavioral health in medicine (88%). Nearly every student (98%) agreed that the new program supplemented their psychiatric education in a positive way, with 82% reporting that they learned a skill or attitude they felt they would not have learned as part of their academic curriculum. Notably, 53% of students did not agree that the clinic should be formally integrated into their required academic curriculum.

This article describes the educational impact of a novel behavioral-health program at a typical student-run clinic. To our knowledge, this is the first published report of a student-run clinic that includes systematic depression screening, longitudinal behavioral health care, and multidisciplinary collaboration between psychiatry and primary-care faculty.

The behavioral health program described here gave all medical-student volunteers exposure to depressive-disorder screening and assessment. It also gave those students particularly interested in psychiatry an opportunity to take part in the ongoing care of patients identified through screening. After program implementation, students were able to diagnose and offer treatment for depression at twice the previous rates, suggesting greater overall awareness of depression. Students reported that this experience led to greater respect for the role of behavioral health in medicine and also predicted that they would pay more attention to behavioral health issues in the future. These results suggest that the student-run clinic served as a place for students to learn broadly-applicable skills in behavioral healthcare and develop positive attitudes about the importance of this work. Future efforts might expand this program to include other common psychiatric diagnoses, such as substance abuse and posttraumatic stress disorder.

The process of screening patients with the PHQ–9 had a number of specific benefits for medical-student psychiatric education. Students reported reinforcement of the DSM-IV criteria for depressive disorders, greater confidence in asking behavioral health-related questions, and normalization of the psychiatric history. However, many students felt the criterion-based PHQ–9 screening tool was not ultimately conducive to considering the patient as “a person,” rather than as a “symptom or illness.” An over-emphasis on this approach may lead students with humanistic interests to pursue fields of medicine other than psychiatry. Further teaching should emphasize that screening is only one aspect of psychiatric assessment and merely a starting-point for greater exploration.

The student-run clinic appears to create educational opportunities that are not optimally provided within the medical school curriculum. Several important factors distinguish student-run clinics from the more-traditional academic experience, and our questionnaire results suggest student concern that some of these distinctions might be lost if the two were integrated. In student-run clinics, participants have substantially more patient-care responsibility than in the standard teaching hospital, where tiers of attending physicians, fellows, and resident physicians often separate students from clinical decision-making. The organization of student-run clinics also requires a high level of teamwork, which may be disrupted by an academic model in which students compete for grades. Finally, the voluntary nature of student-run clinics may foster genuine public service. It might be argued that those students who do not volunteer are the ones who could most benefit from the exposure. However, the introduction of a grading system or other curricular formalization may compromise valuable aspects of the student-run clinic experience. Medical schools might instead encourage student participation through faculty teaching support and through the provision of resources such as access to clinic space.

This study has several limitations. It is a pilot study based on the experience of one clinic; therefore findings may not necessarily be generalized. Also, findings may not be applicable to all medical students, given the potential for selection bias through volunteerism at the clinic. Furthermore, not all students completed the questionnaire, and the questionnaire was not assessed for validity or reliability.

Even with these limitations in mind, this study adds to the growing literature on student-run clinics as unique contributors to medical training by demonstrating benefits specific to psychiatric education. Through the student-run clinic, psychiatric education can expand from pre-clinical didactics and a time-limited clerkship to a pan-educational experience throughout all years of medical school. Although more work is needed to explore the reproducibility of these results, our initial findings suggest that student-run clinics present new opportunities for psychiatry faculty to advance student learning. This article describes an adaptable behavioral-health model in order to provide a blueprint for the start-up of similar programs.

Preliminary results from this study were presented at the 62^nd Institute on Psychiatric Services Annual Meeting in Boston, MA, October 14–17, 2010.

This work was supported by a Helping Hands grant from the American Psychiatric Foundation.

The authors report no financial relationships with commercial interests.