The proper place for psychiatry education and experience in the medical school curriculum has evolved over time. Some institutions have limited the time spent on the required third-year psychiatry clinical clerkship to 4 weeks. Most institutions offer a 6-week clerkship, but there have been questions as to whether maintaining this level of experience is viable, given additional curriculum demands (1).
Within the clerkship itself, change is “in the air.” A traditional experience at many schools has been a clerkship spent entirely at an inpatient facility. Increasingly, there is a call for greater integration of psychiatry and other medical specialties, in addition to clinic-based and longitudinal experiences during clinical clerkships. Diversification of clerkship sites has resulted in opportunities for other models to compete with the familiar inpatient rotation, with similar educational value (2).
Inpatient psychosomatic medicine (PSM) offers several advantages for the third-year clerkship. The patients are admitted to the medical center, so that the third-year clerks experience psychiatric illness in the context of acute and/or chronic medical illness, operationalizing the biopsychosocial model (3–7). Students on PSM services manage several streams of clinical data (including laboratory values and neuroimaging results) and communications from nursing staff and other health professional disciplines. They must interact with physicians from other medical and surgical specialties, receive consultations, and provide recommendations. PSM services regularly manage cases of delirium and dementia, illnesses that are critically important in the general-hospital population (8).
Perhaps most important for third-year students is the opportunity to experience the specialty of psychiatry being practiced in a medical model, co-located with other specialty colleagues, in a collaborative environment. One commonly sees students who possess the empathic and intellectual gifts to become psychiatry residents, yet hesitate to consider the specialty for fear of “not being a real physician anymore.” These students may experience PSM as a model where one can continue to be fully integrated into the medical and surgical environment while still being able to utilize psychiatric assessment and psychotherapy skills. Also, the PSM setting provides a clear example of clinical practice from a biopsychosocial model consistent with the framework taught to students in other specialties.
The University of California, Davis School of Medicine (UCDSOM) has included the PSM service at its major teaching hospital, University of California, Davis Medical Center (UCDMC) among its third-year clinical offerings for over 20 years. UCDSOM requires an 8-week clerkship in psychiatry. The majority of students spend 4 weeks at two different sites. During the last 5 academic years, approximately 25% of third-year students have completed 4 weeks on the PSM service. While on the PSM clerkship, students worked with two PSM faculty psychiatrists, one clinical nurse-specialist, one PG-4 psychiatry resident, and two PG-1 psychiatry residents. The PSM service also trains off-service rotating physicians from family medicine, internal medicine, and neurology. Students were responsible for initial chart review, initial patient interview, integration of laboratory and neuroimaging data, case formulation, treatment planning, and follow-up care, all under supervision of residents and/or faculty members. The PSM service was the only consultation service in the required clerkships in the third year. The two PSM faculty psychiatrists on the service were assigned year-round as their primary clinical service responsibility; these two PSM faculty members also had clinic responsibility for outpatient PSM services in organ transplantation and gastric-bypass surgery.
The authors undertook this study to characterize third-year students’ reflections on the PSM rotation, looking for comparisons and contrasts with other psychiatry clerkship sites at UCDSOM. Specifically they sought to ask whether the data would support the premise that the PSM service offered an integrated experience consistent with the biopsychosocial model. Also, by surveying psychiatry residents at the same institution who had also completed the third-year PSM clerkship, they qualitatively examined the influence that experience as a third-year PSM student might have had on these residents’ motivation to pursue a residency in psychiatry.
This study was approved by the UCDSOM IRB as an “Exempt” study. For the period 2004–09, the 9-item Performance Analysis routinely gathered at the end of MS-3 clerkships was examined. This is a Likert-type scale, where educational goal attainment is rated in response to declarative statements on a scale of 1: Strongly Disagree to 7: Strongly Agree with positive assertions about the educational experience. Also, students’ free-text responses (Site Comments) on their reflections on the PSM clerkship were examined. In addition, a small cohort of physicians who were currently in the UCDSOM psychiatry residency program who had also completed their M.D. degrees at UCDSOM during this period were asked to reflect on how their experience on PSM as a third-year clerk may have affected their motivation to pursue postgraduate training in psychiatry.
On quantitative analysis of clerkship experiences, the students’ ratings of the PSM site paralleled the high ratings for the clerkship overall. On the 9 items, the mean score was 6.0, with a range of 5.3 to 6.3 for the PSM service, with the mean score of 6.2 and a range of 5.8 to 6.4 for all sites. An analysis of the written comments from students about PSM as a clerkship site revealed numerous comments reflecting the students’ appreciation of the specific content of the PSM service. These themes and a number of related comments included 1: Diversity of patient population beyond “pure psychiatric patients” (12 comments); 2: Integration with medicine and application of the biopsychosocial model (7 comments); 3: Application to clinical experience outside of psychiatry (6 comments); 4: Interaction with medical colleagues in other specialties and exposure to an acute-care medical hospital setting (6 comments); and 5: Unique exposure to patients with delirium, dementia, traumatic brain injury, and making decisional-capacity determinations, etc. (6 comments). The reflections of four of the seven psychiatry residents surveyed were similar to those of the students, and typically included an appreciation of the benefit of the integration of psychiatry and medicine and experience in the application of the biopsychosocial model afforded them on the PSM service as students, which was felt to be an important experience in their eventual choice to pursue postgraduate training in psychiatry.
This study covered a 5-year period, during which 25% of UCSDOM students completed a PSM rotation as part of their MS3 core clerkship. The student ratings for the PSM site numerically paralleled the high ratings for the clerkship itself. The free-text comments show that students appreciated the unique aspects of a PSM rotation for their MS3 experience in clinical psychiatry, with themes consistent with our hypothesis.
Perhaps due in part to the success of this clerkship site, the institution where this study was completed had a high rate of students matching into psychiatry residency programs from 2005 to 2009 (range: 6.0%–14.6%; median: 12.0%). The psychiatry residents who had received their M.D. at the same institution had several comments regarding the effect of their experience in PSM on their motivation for psychiatry residency. The comments from students and residents also suggest a uniquely useful role for PSM in assisting those students struggling with the issue of “giving up medicine” in choosing psychiatry.
PSM, a model that, by definition, functions on the medical–psychiatric interface, offers a specifically illustrative experience for third-year students. When students are first exposed to psychiatry, in a purely psychiatric setting, there is always a risk that they will overgeneralize from these experiences and not fully appreciate the significant diversity in patient-care models in the specialty. PSM, by virtue of its medical/psychiatric orientation, presents psychiatry in an integrated model with the rest of medicine. Students on PSM services regularly encounter physicians from many other specialties, who are also working with these patients. Students on PSM services regularly experience important problems such as drug interactions and the systemic effects of psychotropic medication. Given this, one can argue that a medical student’s experience on PSM may be one of the most valuable psychiatry rotations, especially for the 95% of students at most medical schools who will pursue postgraduate training in other specialties.
For the development of a robust MS3 clerkship in PSM, several attributes may be desirable. A PSM service benefits from a viable clinical “load” of patients, so as to ensure adequate and clinically diverse experience. A stable clinical faculty cohort with a primary clinical and academic identity in PSM (rather than coverage by a series of “rotating” faculty) provides for essential supervisory continuity and clinical currency in clinical practice and mastery of the PSM literature. “Building in” of specific PSM content into the pre-clerkship psychiatry curriculum (as is done at UCDSOM) prepares students for clinical encounters in PSM. Integration of student PSM experience with an established and robust resident experience is most beneficial. Finally, training on a PSM service with the regular participation of residents from other clinical departments allows for additional clinical perspective on the cases seen.
Although there are many clear advantages to the PSM site for medical-student clerks, there are possible disadvantages to consider, including the loss of the potential de-stigmatizing effect of working in a traditional psychiatric hospital, with its exposure to actively psychotic patients who cannot be “talked out” of their illness. The PSM site also requires closer supervision of medical students than for the psychiatry residents on these services.
Strengths of this study included a 5-year sampling with good data capture, the benefit of reviewing de-identified data, which encourages frankness in commentary, and the fact that the PSM educational model was under stable leadership and structure throughout the period of the study. Weaknesses of the study involve a retrospective and primarily qualitative design, a lack of data from a period where there was no third-year PSM rotation, and an incomplete response rate on the resident survey.
Schools of medicine and departments of psychiatry should actively consider having a third-year clerkship in PSM routinely available. The clinical experience can be seen by students as widely applicable to a range of specialties. The opportunity to experience and study medical/psychiatric integration on a PSM service is unique to this model. A well-run PSM service, in the context of an educationally strong and student-centered department, can be a significant site for the favorable presentation of psychiatry, and may meaningfully contribute to the recruitment of appropriate students into the specialty.