Increasingly, medical educators appreciate the importance of longitudinal integrated learning experiences and the value of continuity in teaching and mentoring by senior practicing physicians (1–9). Multiple institutions have recently undertaken efforts to provide third-year medical students with experiences of longitudinal patient care, longitudinal mentoring, and the integration of initial clinical experiences in different specialties (10, 11). The Harvard Medical School–Cambridge Integrated Clerkship (HMS-CIC) is one such program (12). Here we offer what is, to our knowledge, the first description of a longitudinal, year-long psychiatry curriculum, designed and implemented over the past 8 years within the overall context of the HMS-CIC.
From a pool of students expressing interest in the program, 12 Harvard Medical students are chosen by lottery to spend their entire third year at Cambridge Health Alliance. They are assigned individual outpatient preceptors in medicine, pediatrics, neurology, psychiatry, surgery, and obstetrics-gynecology, with whom they follow selected cohorts of patients throughout the year. The HMS-CIC also includes several “immersion” experiences in which students focus on a single area, such as surgery, inpatient medicine, inpatient psychiatry, and emergency medicine. Students par-ticipate in varied didactics, including a weekly, case-based tutorial, clinical rounds, and a Patient–Doctor seminar. This model has been described in detail elsewhere (12); it facilitates continuity in clinical care over time, close relationships with teachers, and developmental learning.
Cambridge Health Alliance is a large, public-sector healthcare institution encompassing multiple campuses and clinical services (see Table 1). The patient population is ethnically, socioeconomically, and linguistically diverse, with many individuals having psychiatric illnesses complicated by concurrent medical illness, substance abuse, challenging psychosocial issues, and significant histories of early developmental trauma. Within Cambridge Health Alliance, ample clinical settings exist to give students broad exposure to clinical psychiatry. The core of the psychiatric education consists of evaluation and ongoing care of many outpatients during the year, with regular supervision, mentorship, and teaching from senior physicians, integrated with experiences in other specialties. The outpatient setting includes training in diagnostic interviewing, psychopharmacology, psychotherapy, treatment-planning, continuing care, addictions treatment, the interaction between primary-care medicine and psychiatry, and the opportunity for linguistic and culturally-based clinic experience. Brief, single-topic seminars are given in addictions and geriatrics. Focal immersion experiences are provided in emergency and inpatient psychiatry. A series of case-based, multispecialty seminars includes psychiatric topics, and a year-long Patient–Doctor seminar discusses many psychiatric issues.
TABLE 1.Structure of the Harvard Medical School–Cambridge Integrated Clerkship Psychiatry Program
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|Longitudinal Outpatient Psychiatry Clinic|
| • Initial patient evaluations|
| • Follow-up visits|
| • Psychotherapy experience|
| • Psychopharmacology|
| • Addictions|
| • Consulting Psychiatry|
| • Linguistic/cross-cultural experience|
|Acute Psychiatry Immersion(1-week block)|
| • Inpatient Psychiatry|
| • Psychiatric Emergency Service|
| • Tutorials|
| • Addictions|
| • Geriatrics|
| • Patient–Doctor Seminar|
HMS-CIC students join their psychiatry preceptors in a 4- to 6-hour patient-care session during the clinical hours of the preceptor. Students attend approximately 24 psychiatry clinics over the course of the year. Patients are seen for initial evaluation, consultation, and ongoing care. Typically, in the initial weeks, the student observes the preceptor conducting interviews. Cases are then discussed, with attention to process aspects of the interview, in addition to diagnostic and treatment information. In subsequent months, students conduct evaluation interviews, with observation by the preceptor. These interviews are discussed, and students submit formal write-ups of each case. The student and preceptor develop a cohort of diagnostically-representative longitudinal patients, who are seen in repeated follow-up visits, and for whom the student gradually assumes more responsibility. Capable students may then begin to conduct more autonomous initial evaluations and follow-up visits.
Students observe and participate in a large number of clinical encounters. Over the course of the year, a student completes an average of 10–12 intake evaluations, follows closely 6–12 patients longitudinally, and participates in as many as 6–10 different patient interviews in a single busy clinic session.
The longitudinal ambulatory setting provides an especially rich opportunity for familiarizing students with psychotherapy treatment. Students learn the basic principles of psychodynamic, supportive, cognitive, and dialectical behavioral therapies. General issues such as the development of the therapeutic alliance and its importance regardless of specialty are well covered. Each student is expected to be a participant/observer in at least one continuing psychotherapy of some type. Some preceptors lead therapy groups, so some students learn the principles of behaviorally-oriented group psychotherapy by co-facilitating a group with their preceptor.
Students may be based in a general, adult-psychiatry outpatient department, in primary-care sites, or neighborhood health centers; the latter two sites possess some unique features, which are described below.
Psychiatry Experience in Primary-Care Medicine
In community-based primary care clinics, students work with a senior psychiatrist providing care side by side with the primary-care medicine teams. The preceptor and student follow a consult model in which they see cases referred to them from primary-care medicine, and the preceptors emphasize consultation, co-management with the primary-care provider (PCP), a stepped-care system, and brief or intermittent treatment models. The concepts of collaborative care and integrated treatment are particularly strong in this setting. Attention is paid to medical diagnosis, presentation patterns in primary care, psychiatric implications of medical treatments, and psychiatric treatment integrated with the totality of the patient’s healthcare.
Neighborhood Health Centers and Ethnic/Linguistic Clinics
Cambridge Health Alliance serves a diverse community across a wide spectrum of socio-economic, cultural, educational, and immigration backgrounds. Many patients have undergone serious psychological trauma, and some are sep-arated from their children or other family members, who may reside in other countries. To address the needs of this community, Cambridge Health Alliance has established a number of local heath centers located within ethnically diverse greater Cambridge neighborhoods. These clinics often have a specific linguistic focus, such as Spanish, Haitian Creole, and Portuguese. Several students work with preceptors in these neighborhood clinics, utilizing specific language skills the students are developing, and providing a strong cross-cultural experience for students.
The HMS-CIC psychiatry program includes an immersion experience in acute psychiatry. Each student spends a week with an inpatient clinical team, and at least three half-day rotations in the Psychiatric Emergency Service (PES). This immersion assures exposure to severe psychiatric illness, risk-assessment, and medico-legal issues, and intensive treatment settings. On inpatient units, students participate in clinical interviews, treatment decision-making, and arrangements for continuing care. In the PES, students view the point at which many acutely ill patients first enter the mental healthcare system.
All preceptors teach the assessment and treatment of addictive disorders among dual-diagnosis patients in student caseloads. This clinical experience is supplemented by several didactic sessions, including a case-based tutorial that reviews the pathophysiology of intoxication, addictive behavior, and withdrawal; and experiences that use taped interviews and role-play to teach stage-of-change theory and motivational interviewing.
In geriatric psychiatry, a small-group clinical session on the geriatric inpatient unit focuses on dementia, delirium, and the psychological response to the most common illnesses of aging.
Tutorials in the HMS-CIC are held weekly throughout the year and are co-led by a student and a faculty member. Five of these are dedicated to psychiatric topics, including personality disorders and treatment of the difficult patient; sadness, depression, and bipolarity; the anxiety disorders; schizophrenia; and addictive disorders.
Although not part of the psychiatry program per se, HMS-CIC students participate in a 2-hour biweekly Patient–Doctor Seminar designed to encourage reflection on the cardinal relationships in medicine: doctor–patient, doctor–colleague, doctor–society, and doctor–self. Core topics are covered, but the flexible format is responsive to questions arising for students in their work with patients and preceptors. Seminar topics include reflective practice, physician well-being, professional boundaries, giving bad news, suffering, death and dying, medical culture and the hidden curriculum, sexuality and gender in medical practice, spirituality and religion in medical practice, caring for difficult patients, terminating with patients, giving and receiving feedback, healthy and dysfunctional teams, ethical conflicts, medical error, disclosure and apology, health systems, social context of health and illness, and health advocacy. Poetry, narrative, and art are used to stimulate reflection. Course assignments include three reflection papers, a health advocacy project, participation in an OSCE experience in which the student gives “bad news” to a standardized patient, and a review of at least one videotaped patient interview.
Learning expectations are consistent with Association of Directors of Medical Student Education in Psychiatry (ADMSEP) clinical learning objectives and general Harvard Medical School psychiatry clerkship objectives, with specific elaborations made possible by the longitudinal and integrated nature of the HMS-CIC (see Table 2).
TABLE 2.Learning Objectives
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|Areas of expected developing competence|
| • Clinical interviewing|
| • Clinical work within a team|
| • Case presentation, including differential diagnosis, biopsychosocial formulation, familiarity with and exposure to the major psychiatric DSM-IV diagnoses|
| • Familiarity with systems of healthcare delivery|
| • Psychopharmacology|
| • Cross-cultural sensitivity|
| • The neurobiology and genetics of psychiatric illness|
| • The impact of psychiatric illness on medical conditions, and the impact of medical conditions on psychiatric presentation|
| • The psychotherapies: basic principles|
| • Psychosocial treatment modalities|
| • Refinement of the student’s subjective experience as a clinical tool|
An increasing ability to make progress with substantive professional developmental tasks is explicitly seen in the HMS-CIC as a form of competence that the student is expected to demonstrate. As the year progresses, the student is challenged by existential issues such as life and death, clinical success and failure, clinical autonomy, and the limits of current scientific understanding. The student must deepen and integrate ethics, professionalism, and clinical philosophy. Each student is developing his or her own vision of the patient as a whole person, coupled with the effort to also understand in great detail the illness of the patient, and the treatment of that illness.
Student progress is assessed longitudinally and in cross-section (see Table 3) by ongoing preceptor evaluation; written work, including case reports; the standardized NBME shelf exam; scored patient evaluation interviews conducted by the student and observed by the Program Director; feedback from preceptors in other specialties on aspects of student work relevant to psychiatry; scored OSCE performance exercises; and a consensus-based group discussion among the HMS-CIC psychiatry faculty. The HMS-CIC psychiatry faculty meets as a group four to six times a year, and also participate twice a year in general multi-specialty meetings to evaluate student progress.
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| • Longitudinal preceptor observation of clinical work|
| • NBME subject test|
| • OSCE performance|
| • Clinical write-ups with comments|
| • Clinical write-ups with blind rating|
| • Mid-year integrated student assessment involving all specialties|
| • Scored clinical interview observed by Psychiatry Program Director|
| • Psychiatry faculty consensus grading at year-end|
National Board of Medical Examiners Subject Tests
General educational outcomes for the HMS-CIC have recently been reported (13); here, we focus specifically on outcomes in psychiatry. On the NBME shelf exam in psychiatry, students in the HMS-CIC have scored higher than Harvard Medical School students not enrolled in HMS-CIC (see Table 4). The psychiatry shelf exam is typically taken about halfway into the clerkship year.
TABLE 4.Comparison of NBME Psychiatry Shelf Exam Scores: Students in Harvard Medical School–Cambridge Integrated Clerkship Versus Other Students at Harvard Medical School
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|Cambridge–Integrated Clerkship||Non-Cambridge–Integrated Clerkship|
|Mean||N Students||Mean||N Students|
Table 5 displays performance of HMS-CIC students on the psychiatry station of a comprehensive OSCE taken early in the 4th year, as compared with the scores of all other students at Harvard Medical School. Students in the HMS-CIC have achieved higher scores on the psychiatry OSCE station in every year.
TABLE 5.Comprehensive OSCE Psychiatry Scores
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|Cambridge Integrated Clerkship Versus All Others|
|Cambridge Integrated Clerkship: Year 1||Cambridge Integrated Clerkship||8||75.43||14.02||0.000|
|Cambridge Integrated Clerkship: Year 2|
|(OSCE: 8/2006)||Cambridge Integrated Clerkship||8||61.65||11.40||0.366|
|Cambridge Integrated Clerkship: Year 3|
|(OSCE: 8/2007)||Cambridge Integrated Clerkship||11||66.14||12.79||0.039|
|Cambridge Integrated Clerkship: Year 4|
|(OSCE: 8/2008)||Cambridge Integrated Clerkship||9||69.93||11.48||0.333|
|Cambridge Integrated Clerkship: Year 5|
|(OSCE: 6/2009)||Cambridge Integrated Clerkship||10||68.26||11.97||0.078|
|Cambridge Integrated Clerkship: Year 6|
|(OSCE: 6/2010)||Cambridge Integrated Clerkship||13||69.01||10.55||0.023|
|Cambridge Integrated Clerkship||59||68.17||12.06||0.000|
Although not an aspect of student evaluation, specialty choice among students in the HMS-CIC may shed light on the impact of specialty teaching. Thus far, 48 students from the HMS-CIC have participated in the national residency-matching system upon medical school graduation, and 8 (16%) have chosen to match in psychiatry residencies. This compares with an average of 4.7% per year at Harvard Medical School and about 4.5% per year nationally.
This article outlines the educational structure of a longitudinal psychiatry program within the larger HMS-CIC. Compared with traditional psychiatry rotations, this clerkship offers many advantages, as well as some possible challenges.
Longitudinal Relationships and Experiences
The relationship to one mentor/preceptor over an entire year provides an educational setting of depth and intensity that differs from a short rotation—a setting that may offer particular advantages for learning aspects of psychiatry. The longer educational timeframe provides significant ongoing opportunities to observe in continuing detail processes such as the formation and vicissitudes of the therapeutic alliance; the varying course of psychiatric illnesses in onset, relapse, and recovery; the response within oneself as a clinician to experiences of effectiveness and failure; the ongoing expressions in treatment and societal settings of resilience and vulnerability; the full personhood of a patient over time; and the many systems issues involved in contemporary healthcare delivery.
In contrast, shorter traditional clerkships have greater intensity and focus by allowing the student to become absorbed in only a single subject, but are limited in providing the broader perspective that develops over time. It is perhaps easier for some students to learn while focused upon a single subject, rather than having to learn and integrate multiple knowledgebases simultaneously.
Integration With Other Specialties
The student in the HMS-CIC has the opportunity to follow a single patient through experiences of illness and care in multiple specialties (13). This gives the student an experience of the patient as a whole person, and of the healthcare institution as a whole system; and models for the student the kind of collaboration, communication, and multidisciplinary perspective toward which some clinical settings are evolving (for example, patient-centered medical home models). The experience of the patient as a whole person receiving ongoing multidisciplinary care may also be useful in reducing the stigma associated with psychiatric illness.
In the traditional clerkship, medical comorbidity in psychiatric illness can be emphasized, but less commonly available is the experience of participating in actual treatment episodes over time for concurrent medical and psychiatric illnesses, while being mentored and taught by different specialists.
Psychiatry is a specialty founded upon a developmental perspective, from the level of developmental neurobiology and genetics through the psychological developmental phases of the individual and family life-cycles, into the eras of renewal and decay in the neighborhoods and other social settings in which our patients thrive or fall ill. Major psychiatric illnesses are often chronic, and patients move through a variety of treatment settings, depending on the phases of their illness. The structure of the HMS-CIC provides an opportunity to teach and learn from this perspective and all of these settings.
The entire third year is seen as a coherent developmental experience, and the student is able to learn in a developmental way over time. This reinforces the teaching of psychiatric illness as developmental interruption, and treatment as developmental facilitation. Furthermore, regular evaluation provides a developmental assessment of the student’s growing competency.
In contrast, the developmental aspects of the shorter traditional rotation arise in part from its intensity and single focus, from what might be called its “heroic” aspect (Simon, Bennett: personal communication); but, as a stand-alone experience, it perhaps teaches less about the ongoing long-term nature of illness, health, healthcare, and personhood. Furthermore, the HMS-CIC does contain, as we have described, several “burst” and “immersion” experiences.
The generalizability of our experience in the HMS-CIC may be limited by the specific complexity of the Cambridge Health Alliance system. This complexity provides enormous training opportunities but also makes training logistically and administratively labor-intensive. Any institution’s mix of factors such as public or private sector financial structure, multiple geographic locations, multiple ethnicities and cultural backgrounds of the patient population, and the availability of many or few treatment modalities, would, of necessity, influence the design of a longitudinal clerkship in site-specific ways. We recognize that in a complex and busy system, faculty time for teaching, student evaluation, and program development can be limited; the student’s task in navigating a complex system can be daunting in ways that might be educationally counterproductive for some individuals.
As described in the Results section, students in the longitudinal program performed as well or better than students in traditional psychiatry rotations on standardized measures of learning. Of note, the dedicated hours for psychiatry (indeed, for all specialties) in the HMS-CIC are intentionally the same as in the block-rotation psychiatry clerkships at Harvard Medical School. However, it is true that HMS-CIC students would necessarily have more individualized teaching than traditional students, as intended by the design of the program. In terms of patient exposure, HMS-CIC students are expected to evaluate at least 10 patients over the course of a year, and this may provide students with a broader and deeper experience than other clerkships. We do not have data across Harvard Medical School psychiatry clerkships for the average number of evaluations done, but in the traditional clerkship at our own site the number is typically less than 10.
When strategies for shelf exam success in psychiatry have been investigated (14) team-based learning and combined topic/case discussions were identified as possible contributors to higher scores. Although aspects of these approaches occur in the HMS-CIC as well as other psychiatry clerkships at Har-vard Medical School, we believe that the longitudinal integrated model of close connections with patients and faculty is the key component, for the reasons listed above, that seem to make this model particularly effective for learning psychiatry. For psychiatry OSCE scores, we are not aware of any literature identifying specific contributions to higher psychiatry OSCE scores other than having completed a psychiatry clerkship (15), but we similarly believe it is the model of learning here that is most significant.
Strikingly, a greater percentage of students in the longitudinal program choose to enter psychiatry as a specialty. Although students’ educational experience likely accounts for this finding (as well as the test-score differences), it is possible that there is a selection bias, with students having more psychiatric aptitude or interest choosing the HMS-CIC. When the HMS-CIC was first initiated, a careful analysis of the first 3 years found no difference between HMS-CIC students and others at Harvard Medical School in the following measures: mean MCAT and USMLE Step 1, second-year OSCE scores, plans for future practice, or attitudes toward patient-centered care (12). So, for these years, selection bias was not evident. The considerable extent and consistency of differences seen in all years between HMS-CIC and other Harvard Medical School students are not likely to be explained by selection bias alone.
Several topics merit further study. One area concerns the match of the educational setting to the student. Are there particular kinds of students who do well with a longitudinal, integrated clerkship and others who do better with block-rotation clerkships? A related question is that of specialty choice—what is the explanation of our finding that more HMS-CIC students go into psychiatry? It is unlikely that having an ambulatory setting as the primary clinical experience accounts for this difference; clinical setting has been previously found in one study to have no difference on rate of specialty choice of psychiatry (16). We hypothesize that the longitudinal experience with patients and faculty allows students to develop closer relationships with patients and teachers, to see patients get better, and to experience clinical psychiatry that is more like common psychiatric practice than block-rotation experiences in hospital settings.
A second area of investigation involves the development and retention of empathy in students. An erosion of empathy has been documented in medical students over the 4 years of medical school, with the most precipitous drop measured at the end of the third year (17). Related to this observation are the various perspectives on medical student “burnout” (18). Recent data indicate that the HMS-CIC promotes patient-centeredness in students (13). Do the many unique aspects of the HMS-CIC similarly and specifically contribute to the preservation and deepening of empathy in the student, and do the intentional “learning community” (19–21) aspects of the HMS-CIC help prevent student “burnout?” Suggestive of such an effect are data already emerging from longitudinal aspects of other programs at Harvard Medical School (22, 23).
Also of interest is the impact of educational experience on the young physician’s ability to work in and contribute to new forms of healthcare delivery, such as the patient-centered medical home and accountable care organizations. Cambridge Health Alliance is rapidly evolving toward a system of patient-centered medical homes within an accountable-care organization, and it offers a rich educational setting in which to study healthcare in this model; also, the process of institutional change in medicine is close at hand for the student to observe. Exactly how these educational opportunities affect the student is a topic for further investigation.
Lastly, the reduction of the stigma that students attach to psychiatric illness may be a significant result of a longitudinal experience in psychiatry (24). An examination of this possibility might illuminate more general aspects of stigma-reduction, with implications for the development of other educational strategies aimed at combating the marginalization of psychiatric patients.
Drs. Griswold and Bullock are co-first authors; Drs. Boyd and Shtasel are co-last authors.
The authors thank David Hirsh and Barbara Ogur for their inspiring leadership in developing and directing the HMS-CIC, and also the current co-director, Anne Fabiny; Derri Shtasel, who directed the HMS-CIC Psychiatry program for the first 5 years of its existence; Jay Burke for his support of this project in his role as Chairman of the CHA Department of Psychiatry; Steve Pelletier for assistance in obtaining data; and John MacCumascaigh for assistance in preparing the manuscript. We also thank Carrie Bernstein, Pieter Cohen, Ed Krupat, and Bennett Simon for helpful comments at various points in the development of the work presented here. Finally, we thank all the HMS-CIC students who have inspired us in our teaching, and our colleagues at CHA who have contributed so much to our daily work and teaching.
None of the authors have any conflicts or disclosures related to this paper.