The psychiatry clerkship is at the educational center of the psychiatric curriculum, and for many physicians it is the most concentrated exposure to psychiatric illness and treatment they will have. There is research evidence that the clerkship is the most powerful influence in recruitment into psychiatry (1). Although psychiatric practice has largely moved out of hospitals and into ambulatory settings, most psychiatric clerkships remain inpatient-based. The purpose of this article is to review educational issues raised by a predominantly inpatient clerkship, to discuss the literature from other specialties about the transition of clerkship teaching to include ambulatory settings, and to make recommendations for a similar transition in psychiatry.
The Psychiatric Clerkship
When the Liaison Committee for Medical Education (LCME) mandated a psychiatric clerkship in the 1970s, departments of psychiatry established inpatient-based clerkships, a setting that has dominated medical education since the late 19th century (2,3). Inpatient services allowed efficient teaching because patients were always available, and the trainee could draw on the educational and clinical resources of the hospital and university. Although psychiatric inpatients suffered from severe symptoms of major mental illnesses, it was the prevailing belief in medical education that students needed to observe and treat "pathology writ large" before they could benefit from more subtle examples. Lengths of stay of several weeks allowed students to observe the evolution of the patient's illness, assess the efficacy of treatments, interview families, and then explore postdischarge treatment options. The diagnostic spectrum of most inpatient services was narrow and did not expose clerks to patients with anxiety disorders, uncomplicated mood disorders, and most personality disorders. However, these conditions were largely treated by psychiatrists and were not thought necessary to general medical education.
Recent changes in psychiatric healthcare delivery and reimbursement have greatly changed the educational milieu of inpatient units. Treatment for most patients, even those with psychotic and severe mood disorders, occurs largely in outpatient settings. Inpatient stays are brief and focused on stabilizing patients with decompensating disorders for rapid return to ambulatory status. As Woolliscroft and Schwenk describe it (3), the modern teaching hospital is a large intensive-care unit. Short lengths of stay give students little opportunity to understand the course of illness or explore biopsychosocial contexts. In psychiatry, the acute and often recurrent nature of the patient's condition may reinforce the view that mental illness is devastating in its symptoms and hopeless in its prognosis.
Many psychiatric educators might argue that the present clerkship is ill-adapted to the educational needs of most medical students, who will not become psychiatrists but will diagnose and treat patients with psychiatric disorders (4). It is also ill-suited to giving medical students a realistic idea of psychiatric practice. One wonders if clerkship teaching, which exposes students to the most refractory examples of illness, has played a role in decreased recruitment into psychiatry in the 1990s, much as a parallel phenomenon in internal medicine reduced recruitment into that specialty in the 1980s. This may help explain the finding by Balon, Franchini, Freeman and others that whereas medical students have a fairly positive view of psychiatry's efficacy, they do not choose it for their own careers (5).
Despite dissatisfaction with inpatient clerkships, psychiatry has lagged behind other specialties in creating outpatient experiences. Hunt and Lentz (6) surveyed medical schools in 1983 and reported that 46% had outpatient components built into clerkships, and another 18% had optional ambulatory experiences. The length of ambulatory experiences and the percentage of clerks who participated were not specified. Abrams and colleagues (7) reported in a 1985 survey that there were few outpatient opportunities for clerks.
The National Board of Medical Examiners surveyed one-fourth of students from United States and Canadian medical schools who took United States Medical Licensing Examination (USMLE) Step 2 during the 1997—98 and 1998—99 academic years. Students were asked the number of days spent in outpatient settings during third-year clerkships. More than one-third of students had no ambulatory experience during their psychiatry clerkship, and two-thirds had 5 days or fewer. The percentages of students with 5 or fewer days' ambulatory experiences during other clerkships were 7% in family medicine, 13% in pediatrics, 25% in OB/GYN, 30% in internal medicine, and 41% in surgery (Ripkey DR, Case SM, unpublished).
Impediments to outpatient teaching in psychiatry are thought to include issues of patient care, institutional constraints, and the unique nature of the doctor—patient relationship. It is felt that treatment by medical students interferes with continuity of care and may compromise confidentiality. Other conditions that might be obstacles are limitations of space, necessity to provide outpatients for residents, and the priority for clinic-based attending physicians to treat a high volume of patients.
As compared with other medical specialties, psychiatry has made little use of private practitioners for teaching. The influence of psychoanalysis, with its emphasis on the transference as a major source of clinical information, established the need for absolute privacy between doctor and patient. Although the nature of practice has changed, and many practitioners treat patients by use of a medical model that could accommodate students, the peripheral role of private practice has not been reevaluated.
Ambulatory transition in clinical clerkships.
In considering ambulatory teaching in the psychiatry clerkship, it is useful to review the experiences of other specialties in effectuating this transition. The changes in third-party reimbursement that have so altered psychiatric hospitalization in the 1990s occurred in most other specialties in the 1980s when diagnosis-related groups (DRGs) decreased inpatient lengths of stay and shifted evaluation and treatment to ambulatory settings (8). In a study comparing discharge data from 1980 and 1986 at a university-affiliated teaching hospital, Rosevear and Gary (9) found that by 1986, the average length of stay for patients with the most frequent discharge diagnoses had declined 34%. This shift necessitated a response by medical educators, who saw shrinking opportunities in hospitals. At the same time, changes in national healthcare policy and educational attitudes toward primary care created an intellectual climate that was enthusiastic about teaching ambulatory care (10).
During the 1980s and 1990s, departments of internal medicine, family medicine, and pediatrics integrated outpatient experiences into required clerkships, using university and community-based clinics (11,12), HMOs (13,14), and private practices (15). In a study of internal-medicine departments in 1989 (16), 24% of responding departments required ambulatory care experience in the clerkship, and 20% offered courses that satisfied a selective requirement in ambulatory care. By contrast, in 1996—97, only 5% of internal-medicine clerkships were exclusively inpatient-based (17).
In general, ambulatory experiences have been successful. Clerks can learn the natural history of illnesses by following patients with the same diagnosis during different points along the spectrum of illness and recovery and assess the impact of diseases on patients and families. The case mix is important to demonstrate that some patients function well with diseases perceived as hopeless in inpatient settings, whereas others demonstrate the catastrophic life consequences of illness that may not be apparent during an inpatient stay. The financial and social impacts of illness are more readily recognized when the patient is living in the community (3).
Clerkships have adopted either a block or longitudinal model in integrating outpatient experiences. In the block model, clerks rotate from inpatient to ambulatory teaching sites full-time for a number of weeks. In the longitudinal model, clerks are inpatient-based, but spend part-time each week in an outpatient setting for the duration of the clerkship. Studies have reported advantages of both models (16,18—22).
The block develops confidence in history-taking and doing procedures, probably because of its intensive and concentrated nature. Clerkship directors prefer it because it is easier to organize and monitor (16). In one study comparing block to longitudinal experience during an internal-medicine rotation, students preferred the longitudinal experience, but the block was more successful in recruiting students into internal medicine (18). Studies of the longitudinal experience show high student satisfaction. Students value the opportunity to form relationships with supervisors and to follow patients over time (19).
In a review of teaching and learning in ambulatory settings, Irby (21) reports "education in ambulatory care clinic is characterized by variability, unpredictability, immediacy, and lack of continuity." The demand that both students and teachers see a volume of patients in a relatively short period greatly influences the context and content of teaching. Teaching interactions tend to be dyadic rather than team-based, case- rather than illness-specific, brief, and focused on immediate management issues (21,23). Not every student case is reviewed by faculty (24,25), and "learning by doing" is typical. Numerous studies confirm that direct patient care, rather than patient observation, is vital to student learning, satisfaction, and self-confidence (15,26,27). The absence of teaching rounds that address all the on-service patients and use the specific case to teach general principles means that students' education may be too narrowly focused on their particular case mix (28,29).
The lack of uniformity among ambulatory teaching sites requires the course coordinator to provide a consistent education by defining explicit educational goals. There must be clear standards that describe the student caseload in terms of numbers and diagnostic mix and provide guidelines for faculty supervision. Faculty development is necessary to train clinical teachers in educational methods. It has been suggested that departments create "teaching scripts" that emphasize the major teaching points for common illnesses (21). Centralized formal teaching during the clerkship is probably necessary to supplement clinical experiences and ensure that students are exposed to a basic curriculum (30,31).
The rewards and costs of student teaching in ambulatory settings have been widely reviewed (8). In general, clinicians value teaching and consider this a legitimate demand on time and resources (32,33). Although there is some debate, the preponderance of data suggests that primary care doctors spend somewhat more time in the office and see somewhat fewer patients when teaching third-year medical students (32,33). The financial cost of teaching is less clear, and reports are contradictory.
At the present time, most private practitioners and ambulatory care clinics are not paid for teaching students, though other forms of faculty reward and recognition are provided. As medical student education makes increasing use of outpatient resources, it is probable that this will change. Various proposals to reimburse outpatient teaching have been offered. Perkoff (34) suggests clinical income in medical schools be considered school income rather than department income and a portion of these earnings be distributed to support teaching. Hospitals should return some inpatient-generated funds to their ambulatory settings as another means to support education. Others have suggested using core funds of the medical school designated for education to reimburse ambulatory teaching sites (35).
Ambulatory care and the psychiatric clerkship.
There has been considerable interest in recent years in developing outpatient experiences during the psychiatry clerkship. However, there is no recently published review or national survey that reports what has been tried and what has proven successful. Most of the information about outpatient teaching is anecdotal. Ambulatory programs have been developed in VA subspecialty clinics, urban and rural community mental health centers, university-sponsored primary care centers, an evaluation unit at a county jail, and a rural outreach program (36).
Both Christensen (37) and Rodenhauser (38) describe successful teaching programs in rural community mental health centers. Christiansen stresses that the outstanding social and financial needs of this patient population encourage students to plan treatment that integrates the biopsychosocial point of view. Rodenhauser's observations that student satisfaction is correlated with opportunity for direct patient care and the teaching style and enthusiasm of the preceptor is in accord with reports from the primary care literature.
Two studies describe follow-up of outpatients seen by third-year psychiatry clerks in extended evaluation or short-term supportive psychotherapy. Hunt and Lentz (6) report that 80% of patients evaluated by medical students were satisfied with their care, as compared with 73% of patients evaluated by residents. Werman et al. (39) state that 83% of patients treated weekly for 3—8 weeks by medical students reported some or much improvement. Frank et al. (40) describe a psychotherapy-oriented outpatient clerkship that teaches skills of psychodynamic time-limited psychotherapy. Students assigned to this rotation were more likely to choose psychiatry for a career than were students assigned to the traditional clerkship. It is not clear if outpatient clerks were self-selected or randomized. Given that each outpatient clerk received 5 hours of supervision per week, this model is probably not feasible in the contemporary practice climate.
It is clear that trends in patient care and reimbursement that favor outpatient treatment will persist and will require changes in the clerkship. We must review educational goals and determine what clinical setting can best achieve them.
Inpatient services provide a generally safe and supervised environment in which to learn to evaluate and interact with psychotic people. Patients' dramatic symptoms and rapid responses to medication make indelible impressions. Students are well served by the traditional academic focus and institutional supports. The inpatient unit probably remains the most efficient setting for teaching basic psychiatric skills and knowledge.
It is important for students to learn that patients with serious psychiatric illnesses work and live independently and that their success is often achieved with support from their families and the mental health resources of the community. Hospital-based outpatient clinics, community mental health centers, and partial hospitalization programs provide access to patients with stabilized mental illnesses and teach appropriate optimism. These settings lend themselves more easily to teaching a biopsychosocial point of view then do acute inpatient services. They are reliable sources of outpatients and allow clerks to gain supervised experience in supportive psychotherapy. It would be useful to form or expand ties with other community-based facilities serving populations in need of psychiatric services, such as drug-treatment programs and shelters for homeless persons and for battered woman. These settings might welcome psychiatric evaluation and treatment done by medical students supervised by faculty.
As treatment of common psychiatric conditions such as mood, anxiety, and somatoform disorders becomes an important aspect of primary-care practice, it is necessary to teach students about these conditions. We imperil the future of the clerkship if we remain unresponsive. Outpatient clinics, subspecialty clinics, and psychiatric private practices all provide access to patients with these disorders.
Primary-care physicians suggest that the symptoms of psychiatric disorders seen in their practices often differ from those in classic DSM-IV profiles and that they and the patient may have treatment agendas that differ from those of the psychiatrist (4,41). Psychiatric on-site participation in primary-care offices and outpatient consultation/liaison services are excellent settings in which to teach treatment of common psychiatric illnesses, techniques for managing difficult patients, and skills of supportive psychotherapy.
Of course, research and clinical interests of psychiatry departments will enrich basic educational goals. Experiences with children, families, and elderly patients will be offered in some institutions, as will experiences with different treatment modalities. Perhaps a first step in expanding ambulatory offerings is to create a menu of "ambulatory selectives" for the clerkship, chosen to reflect the strengths and resources of the department.
Because the average psychiatric clerkship is 6 weeks, and many anxiety and mood disorders and some psychotic disorders show an initial response to medication and supportive psychotherapy within this time, it should be possible to offer clerks an outpatient experience that provides patients reasonable continuity of acute care. Students can be assigned to an inpatient service part-time throughout the clerkship and spend several half-days each week in outpatient settings. If this is too difficult to coordinate, block rotations are reasonable, provided clerks are assigned patients with similar diagnoses at different points in their clinical course.
If psychiatric clerkships are to offer meaningful experiences in ambulatory care, departments must forge links with private practitioners. The number of students who rotate through the clerkship will challenge efforts in all but the largest departments to provide ambulatory teaching within traditional university-sponsored settings. Geographic full-time faculty and recent residency graduates who already have close affiliations with academic departments may be willing to teach clerks. Many of the strategies for establishing clerkship links to primary-care office practice and evaluating their effectiveness are applicable to psychiatry (15).
Although the task of student teaching is integrated into service expectations on inpatient units, there is not yet a medical student teaching culture in ambulatory settings in psychiatry. In the zeal to increase student experiences, it is important to avoid the wishful idea that to place students in outpatient settings is to teach them outpatient psychiatry. Faculty from inpatient and outpatient settings must be included in developing comprehensive educational goals and procedures that are coordinated across sites to minimize overlap and omission. Student logs of patients are a helpful way to monitor the clinical diversity of student experiences.
Regardless of the ambulatory setting, educational research from primary care provides important guidance about clerkship training requirements:
1. Students must be given direct patient care responsibilities. Insurance requirements may restrict the ability of students to examine patients independently. Nonetheless, they must perform examinations rather than observe the attending physician.
2. An ambulatory care curriculum must be created and should include self-directed learning exercises, centralized conferences to provide core teaching, and guidelines for clinical supervisors that specify points to be made for each psychiatric illness and treatment.
3. Faculty needs to be trained in methods of teaching, supervision, and evaluation. This should be done at the beginning of each academic year, with debriefing at the end of the year. An education retreat with CME credit may provide faculty reward, but brief on-site sessions will be better attended.
4. Assessment measures for outpatient services must be developed. Clinical encounter forms that rate student performance after each patient interaction may be a more reliable measure for busy outpatient settings than the end-of-rotation summary evaluation used on many inpatient services.
5. Volunteer faculty must be rewarded with some valued payback. Money is always appreciated. Short of that, computer access to university information systems, teaching awards, educational conferences, and the gratitude and interest of the course coordinator are useful.
6. There must be departmental support for clinical research in ambulatory care so that faculty do not perceive outpatient teaching assignments as compromising their academic careers.
A national taskforce for psychiatric teaching in outpatient settings would be extremely useful. The taskforce could survey clerkship directors to ascertain current outpatient teaching sites, curricula, evaluation techniques, and student and faculty assessments of the program. The taskforce could organize multi-university collaborative projects to develop and evaluate outpatient teaching settings. This would generate useful samples for educational research much more quickly than single institution research. The taskforce could create a model curriculum for outpatient psychiatry and develop standard evaluation forms. Organizations concerned with medical student education, such as ADMSEP and AAP, would be logical coordinators of this effort.
The transition of the clerkship to include a meaningful experience in ambulatory psychiatry willrequire much tact and planning. However, it offers the chance to convey a realistic view of psychiatry and is a worthy endeavor for medical education.