While there is a perpetual focus in the psychiatric literature on manpower, recruitment, attitudes, and experiences during the third-year medical student psychiatry clerkship, we know much less about other aspects of medical student education, such as the characteristics of the teaching faculty itself. Such characteristics could be important for the recruitment of medical students into psychiatry. Sierles (1) reported that the best predictor of psychiatry as a career choice was the academic rank of the director of medical student training in psychiatry—the higher the better. A MEDLINE literature search in 1996 (for years 1967—1996) and a survey of the 1990—1996 volumes of Academic Psychiatry (not included in MEDLINE) revealed one article by Sierles and Magrane (2) on psychiatry clerkship directors. This article reported results of a larger survey on psychiatry clerkship directors in 1994. The survey was sent to 128 medical schools (126 American, 2 Canadian), and responses were received from 107 schools (83.6%). The average clerkship director was 46 years old and had directed his/her clerkship for 5.9 years, while 30% had been directors for 2 years or less. Ninety-four percent of the directors were psychiatrists, all board-certified, with some having subspecialty qualifications. The majority were professors or associate professors. Ninety-one percent of the clerkship directors held one or more additional administrative positions (e.g., director of medical student education in psychiatry). Besides demographic characteristics, Sierles and Magrane (2) focused on the attitudes of these clerkship directors. The researchers reported that most clerkship directors viewed their role as fulfilling and wanted to direct the clerkship for the rest of their careers. Most, however, also perceived that their medical school was not providing enough support, that faculty were not teaching enough, and that the current economic climate impeded learning.
We decided to gather more detailed information about the directors of medical student education in psychiatry and to determine a "national profile" of the faculty members responsible for medical student education in psychiatry. We completed our study before the Sierles and Magrane article (2) was published. While our survey focused more on demographic characteristics, funding, research, and directors' clinical and scholarly activities, Sierles and Magrane (2) focused, in addition to demographic characteristics, on clerkship directors' attitudes and career aspirations.
A 27-item questionnaire developed by the authors was sent in a single mailing to individuals at 132 medical schools (126 allopathic and 6 osteopathic) in October 1995. The mailing list was compiled from the membership directory of the Association of Directors of Medical Student Education in Psychiatry (only one name per medical school was used), and the names of persons responsible for medical student education or department chairs from the Directory of Psychiatry Residency Training Programs (3). Each questionnaire packet included a personalized explanatory letter and self-addressed, stamped return envelope. The questionnaire was constructed to preserve the confidentiality of respondents. According to the Chair of the Human Investigation Committee of Wayne State University, a specific written consent was not required for this study.
As of April 1996, 84 schools responded. One school had two co-directors who completed the questionnaire jointly. One director was in charge of two classes at two recently merged medical schools and answered some questions separately for each class. Response rate was 64 %.
Descriptive statistics (including mean and standard deviation [SD]) whenever appropriate) were calculated for each question. Association between gender and rank and gender and number of publications was examined using chi-square. Further gender differences were examined using the Mann-Whitney U test, an analysis of variance, and logistic regression model.
The results are summarized in T1A and T1B.
Further Results and Comments
Gender distribution of our study's respondents is as follows: 67% males, 30.6 % females, 2.4% did not answer, which roughly parallels the demographics of the American Psychiatric Association's membership (71 % males, 29 % females).
There were 47 U.S. allopathic schools named. Twelve schools were named more than once.
Residency Training in Psychiatry.
Eight individuals listed training in another specialty: four in internal medicine (one incomplete), one in "general preventive medicine," one in neurology, one in nuclear medicine, and one in surgery (incomplete). The only physician without residency training in psychiatry trained in internal medicine. Thirty-six individuals listed various "subspecialty or qualification training,": child psychiatry (9), consultation/liaison (5), geriatric psychiatry (4), psychoanalysis (4), and psychopharmacology (2).
Board Certification in a Psychiatric Subspecialty.
Two individuals listed certification in more than one psychiatric subspecialty. The most frequent certifications were in child psychiatry (7), geriatric psychiatry (4), addiction (3), and adolescent psychiatry (2).
Board Certification in Another Specialty.
Three individuals listed training in another specialty: internal medicine, neurology, and general preventive medicine.
How Soon After Residency Appointed as Director.
The mean±SD time was 8.8±8.9 years, mode was 0, median 5 years, and range 0—31 years.
The mean± SD duration of being a director was 5.3±4.8 years, mode was 3 years, median was 3 years, and range 0—27 years. Three individuals did not answer. There was no correlation between years as director and how soon after residency the director was appointed (r=−0.09, P=0.43).
More women were at lower ranks (chi-square test of linearity=8.48, df=1, P=0.004). This finding remained significant even if the rank of instructor and assistant professor were combined (P=0.018). Rank can be influenced by the number of years since residency completion. Rank was clearly related to the number of years since residency completion in our study (P<0.0001). The median number of years for women was 3, for men 6 (Mann-Whitney U, P=0.003). However, number of years as director did not differ by gender (Mann-Whitney U, P=0.28). Further, we used a logistic regression model with rank as the dependent variable and gender, number of publications, and years postresidency as independent variables. Gender did not predict rank (P=0.45).
The category "other" included these orientations: cognitive-behavioral (2), neuropsychiatric (2), medical (1), phenomenological (1), and pragmatic (1).
Length of Psychiatric Clerkship.
Other responses included 5 weeks (4), 9 weeks (1), and 7 weeks (1). Two 8-week clerkships and one 9-week clerkship were "split" between the third and fourth year. One 8-week clerkship was combined with neurology. In one recently merged school, one clerkship was 6 weeks, and in the other was 8 weeks.
Funding Source of Medical Student Education at Directors' Medical Schools.
The university's general fund included the response "medical school budget." "Split funding" included various combinations (e.g., general fund+state, general fund+faculty practice).
Percentage of Director's Time Spent in Education, Research, and Clinical Work.
In addition to their functions as directors of medical student education, two respondents are assistant deans and one is a residency training director.
Two of the 23 individuals had received external funding in the past. Funding sources were as follows: federal (10) (one 10%, 1 in the past); drug companies (12); state grant (1); VA grant (2); and private foundations (4). Some individuals received more than one source of funding. Out of the 23 respondents who were receiving external funds, 8 were funded before being appointed director, 11 during the directorship, and 4 both before and during the directorship.
Approximate Number of Publications.
The mean±SD number of publications was 24.8±36.4 (range: 0—181). The men had significantly more publications than the women (Mann-Whitney U, P=0.01). For example, 68% of the women had fewer than 10 publications vs. 33% of the men. As number of publications may indicate research experience, we examined if the respondents have or ever had research funding. Only 16% of the women and 30% of the men had, but these percentages are not significantly different (χ2=1.74, df=1, P=0.19).
When asked if research was a major activity, 24% of the women responded affirmatively vs. 47% of the men (χ2=3.95, df= 1, P=0.047). We also used an analysis of variance with the log of publications (after adding 0.5 to those without any publications) as the dependent variable. After controlling for length of time postresidency, the women as a group had fewer publications, but the effect is diminished (P=0.09).
Number of Peer-Reviewed Publications.
The mean±SD of peer-reviewed publications was 16.9±27.3 (range: 0—122).
Involvement in Other Major Educational Activities.
Most of the respondents listed more than one major activity. Three out of the 22 directors who participated in school admissions have done so in the past. Other activities included medical staff committees, teaching analytical candidates (2), residency admissions (2), continuing medical education, Liaison Committee on Medical Eucation participation, and residency training directorship.
Items Not Listed in T1A and T1B.
Directors' Special Interest.
Seventy-two answers included numerous areas of interest. Areas listed more than once were anxiety disorders (6), mood disorders (6), consultation/liaison (5), attention-deficit hyperactivity disorder (4), posttraumatic stress disorder (4), emergency psychiatry (3), sleep (3), addictions (3), schizophrenia (3), as well as brain imaging, cultural psychiatry, forensic psychiatry, geriatric psychiatry, human immunodeficiency virus (HIV), psychopharmacology, personality, and sport psychiatry or psychology (all 2). Thirteen individuals did not answer this question.
Approximate Class Size at Medical School.
Approximate mean±SD class size was 131±51.4 students (range: 15—280). Three individuals did not answer.
Others Involved in the Administration of Medical Student Education.
Two directors shared administration equally, while another director administered two classes in a combined school. Fifty-four directors shared the administration with 1 or more assistants (physicians), 23 directors had no assistant (physician), and 7 individuals did not answer. Seventy-one directors listed support personnel: 34 had 1 support person (4 of these support people were employed half-time), 19 had 2, 4 had 3, 1 had no support personnel, and 13 did not specify the number. Fourteen individuals did not answer.
Results of this study present interesting data about directors of medical student education in psychiatry in the United States, their characteristics, interests, activities, and economic realities of their position. Some of our findings confirm anecdotal observations and beliefs.
The directors are younger, mostly male (2.2:1 ratio), mostly graduates of U.S. medical schools, who graduated mostly in the 1970s and 1980s (1982 the leading year). Almost all are trained in psychiatry and are board-certified in psychiatry, with about 25% certified in a subspecialty (child psychiatry was the leader). They were appointed director on an average of 9 years after residency and have been directors on average for about 5.3 years. However, the median number of years after residency for the women was 3 and for the men 6 years.
Their faculty rank varies—most are assistant professors (32) and associate professors (25). Many directors are on a clinical track (30), with the educator track being a distant second (15). They describe themselves as being mostly eclectically oriented and having wide-ranging interests. These demographic findings are similar to those of Sierles and Magrane (2) who surveyed clerkship directors.
The directors usually teach or organize teaching in more than one class (almost half of them in all 4 years), with an average class size of 131 students and an average clerkship length of 6.4 weeks (half of the schools had a 6-week clerkship). They are usually assisted by other faculty and support personnel. Medical student education in psychiatry, by their description, was mostly funded from the university's general fund, the state, or from combined sources. The directors' salaries are mostly funded from a combination of resources (one-half of the respondents) or from the university's general fund, or from the state; however, we did not ask what percentage of the salary is generated from which source. Research salary from a grant might be desirable; clinical salary, if not excessive, might be by choice to augment traditionally low academic salaries. Less than one-third of the directors have received external funding. The wisdom of the practice of frequently generating salaries (50%) from several sources might be questioned by some, but likely unavoidable in the current economic climate.
The directors are mostly involved in clinical and educational activities, spending about 42% in education, 37% in clinical work, 9% in research, and 11% in other activities (administration). More men than women endorsed research as their other major activity (P=0.047). We can only speculate about this finding; however, women generally tend to have more obstacles in pursuing a research career. Sierles and Magrane (2) reported that most psychiatry directors perceived that conducting research was not essential to their teaching.
The directors are also active in the process of writing, with an average number of 25 publications (usually less than 20, with a wide range of 0—181). The male directors had more publications than the women. After controlling for length of time after residency, the women still had fewer publications, but the difference was markedly diminished (P=0.09).
The directors are also quite active in other various academic activities, such as participation in major medical school committees (89%), teaching residents (91%), and teaching other specialties (52%) and disciplines (51%). Only 26% have participated in the medical school admission process.
The directors of medical student education who responded are board-certified, eclectic, have a wide range of interests, and participate in various activities at the departmental and medical school levels. The job of the director of medical student education is not a long-lasting one (mean±SD: 5.3±4.8 years) (Sierles and Magrane (2): clerkship directors: 5.9±5.3). Forty-one directors (48%) have been in their positions 3 years or less (Sierles and Magrane (2): clerkship directors: 30% less than 2 years). Even though the mean±SD time between residency and appointment as a director was 8.8±8.9 years, 9 of our respondents were appointed immediately, 7 within 1 year, 5 within 2 years, and 7 within 3 years, which indicates a 33% replacement rate within 3 years of residency training. Interestingly, three directors were not trained in psychiatry. There was also no correlation between years as a director and years between residency and appointment as a director. It is not clear how much of our results on high replacement rate is attributable to internal and/or external factors. However, one could infer from the data that the position of the director of medical student education is not a stable one.
Our study had several limitations. The response rate of 64% is fairly good for a single mailing, but the possibility of sampling bias exists. Because it was a mail survey, some questions could have been misinterpreted. Further, we did not ask what percentage of the director's salary was generated from other sources. Finally, the responses were not completely anonymous, as the director could be identified from school of graduation (8 did not answer) and from the postal mark on the return envelope (for states or cities with only one medical school). Incomplete anonymity could have contributed to the nonresponse rate of 36%.
We believe that one of the primary missions of medical schools is medical student education. During times of limited resources, increased clinical responsibilities, and managed care, one major area of concern is the support given to the faculty who are responsible for educating medical students (2). There is a definite need for more "seasoned" faculty (1) who have staying power and have enough time to teach and direct medical student education. There is also a need to further study the impact of the "unstable" quality of the position of the director of medical student education on medical student education itself.
The authors thank Cynthia Arfken, Ph.D., for statistical help and Renee McBride, Jennifer Standish, and Helena Balon, M.D., for their help with manuscript preparation.