Historically, most psychiatric medical student education has occurred on inpatient units (1—3). However, this method is less than ideal given the recent changes in the nature of inpatient psychiatric practice (4,5). Only a fraction of patients with psychiatric problems are ever hospitalized (6), and those that are admitted usually present with a high level of distress (4). An inpatient experience provides limited exposure to a narrow range of disorders that includes only the most severe manifestations of psychiatric illness, making it difficult for the student to gain skill in detecting subtle indicators of psychiatric problems (6). In contrast, ambulatory settings provide exposure to many points along diagnostic and severity continuums. Additionally, the ambulatory experience gives students the chance to observe and participate in the ongoing care of various clinical problems.
A second issue related to the appropriate practice setting for medical students concerns the high prevalence of psychiatric conditions seen in primary care settings (1,3,7—10). Studies have shown that 30% to 40% of patients presenting to a primary care physician meet criteria for either a primary psychiatric problem or a secondary psychiatric disorder complicating a general medical condition (10). In other words, physicians' offices and outpatient mental health clinics are where most patients with psychiatric problems are found. In order for medical students to be exposed to a full spectrum of psychiatric presentations, it is important for educators to increase exposure to both primary and specialty ambulatory settings (1,3).
Some efforts have been made to incorporate ambulatory experiences into the core psychiatry clerkship. For example, students are often asked to observe experienced clinicians conducting evaluation and treatment sessions. Additionally, students commonly attend supervision sessions or team meetings to allow exposure to multidisciplinary treatment planning and case management (11). Unfortunately, most students find these learning experiences to be passive and unfulfilling. Clearly, a move toward greater participation within the ambulatory setting is needed.
The objective of increasing the amount of medical student participation in ambulatory settings in psychiatry is not easily achieved. Privacy and confidentiality concerns often lead patients and clinicians to balk at direct medical student involvement. Another difficulty in attempting to include medical students in direct psychiatric care is that there is little opportunity to arrange for clinical encounters that have progressively more challenging elements. In other medical specialties, the standard practice is to offer learning opportunities along a continuum from elementary to more advanced procedures. For instance, a student assigned to a primary care clinic can begin by taking vital signs or removing sutures before progressing to more complicated endeavors such as cardiac or pelvic exams. In contrast, psychiatric practice is more difficult to subdivide. During new patient evaluations, patients often describe their experiences in a nonlinear fashion, making it difficult to assign a specific elementary portion of the interview to a medical student. Similarly, ongoing psychotherapy sessions are difficult to separate into discrete standalone components. Therefore a tension is created between the need for active student participation and the nature of psychiatric outpatient services delivery. Clearly, it is important that educators in psychiatry find a way to overcome this tension in order to provide a participatory experience for medical students in an ambulatory setting. A description of our new program aimed at increasing participation and active learning follows.
During our four-week clerkship, students are assigned to one primary site, either the adult inpatient unit, the child and adolescent inpatient unit, or the consultation-liaison service. In addition to these primary placements, students are assigned to the enhanced ambulatory experience one day each week. During this day, four students leave their primary sites and come to the adult outpatient clinic.
Educational Interview and Group Practice
The ambulatory experience has three major components. The first component is an educational interview. During the first week of the clerkship, the students meet with a faculty facilitator (usually T.G.) to view and discuss another faculty member's initial patient evaluation, shown on videotape. The videotaped interview gives the student a chance to observe the establishment of clinical rapport, engagement, and empathy, and to witness sequential pacing of the interview. During weeks 2, 3, and 4 of the clerkship, students encounter well-trained simulated patients who portray increasingly complex clinical psychiatric presentations. The students interview the simulated patients with a faculty facilitator (usually T.G.) present. The simulated-patient presentations are quite complex and involve two cases where students are called on to distinguish between alcohol or sedative-hypnotic use/abuse and affective disorders. The third case is a fairly complicated portrayal of panic disorder. All four students interview the simulated patient in a round-robin format, allowing for opportunities to interrupt the interview for important teaching points and to engage in small-group discussions related to the interview.
In clinical settings with an actual patient present, teachers often find it difficult to provide immediate feedback to the students. The simulated-patient experience allows the facilitator to take a break at any point in the interview and "stop action" to point out problematic interactions between the student and the simulated patient. This often provides an opportunity for the student to repeat a specific section of the interview, receiving feedback from the faculty facilitator. In actual patient encounters, negative comments from an attending physician often lead to students feeling chastened in front of patients. Additionally, if attending physicians do give students critical feedback with a patient present, the patient may feel embarrassed for the student, uncomfortable, and possibly uncared for given that the focus has shifted away from the patient's concerns.
The simulated-patient interview offers a unique occasion for peer interaction and learning. Students often give each other valuable suggestions about a variety of ways to obtain needed information, in addition to providing suggestions regarding the next logical direction for the interview. At the conclusion of the interview, the faculty facilitator solicits feedback directly from the simulated patient for each individual student. Our well-trained simulated patients give very specific targeted information and advice based on their own emotional reactions and perceptions experienced when they were "in character."
To date we have not used the resource of videotaping these sessions for student feedback. The simulated-patient experience is especially helpful for videotaping because attention to confidentiality issues and patient informed consent are not required. Overall, the group simulated-patient interview provides a unique opportunity to put educational needs before patient care issues.
Evaluation of New Patients
The second major portion of the ambulatory experience is student-conducted new patient evaluations. During each of the four weeks, students are paired with either a 4th-year psychiatric resident or a faculty member, during which time a new patient is evaluated. New patients are placed on the medical student team schedule by our department's centralized scheduling office. Prospective patients are asked if they would be willing to allow a medical student to participate in the interview. If they agree, they are told a physician will be present for the entire evaluation, and verbal consent to participate is obtained. The intake social worker screens out any patient who endorses only substance abuse or requests marital treatment, or when personality disorders appear to be the primary complaint. Obviously there can be discrepancies between telephone screening and the actual in-person presentation. It is important to note that the intake workers are not instructed to assign only those patients who present with "straightforward" or "uncomplicated" complaints. Unfortunately, there are no data available regarding the numbers of patients who decline when they are asked to be seen by the medical student team. However, the primary-intake social worker estimated that half of the patients decline participation.
During new patient evaluations, our emphasis is on providing an environment where the medical students are able to perform as much of the interview on their own as they are capable of doing, with an experienced psychiatrist present to complete the evaluation. Follow-up patient care is the responsibility of the evaluating resident or faculty member. The "medical student team meeting" immediately follows the new patient evaluations. In this venue, the students formally present new cases. An advantage of this practice over a traditional multidisciplinary team meeting is that the discussion in the medical student team can be tailored to the educational level of the medical student. These meetings often foster lively discussions regarding the interview process and also provide an opportunity to give constructive feedback to medical students regarding their evolving clinical and formal presentation skills.
Participation in Clinical Care
The third part of this experience involves student participation in continuing clinical care. The medical student and the assigned mentor provide ongoing treatment for patients who have previously agreed to medical student participation. Usually each student sees two such return-visit patients per week. In the best of circumstances, these return visits include patients who were evaluated initially through the medical student team; however, other routine clinical cases are also interviewed. Return visits are often the most passive component of the revised ambulatory experience. Limited student participation is due mainly to the need for expedient medical decision-making and the complexities of psychotherapeutic treatment.
It is hypothesized that the enhanced ambulatory experience will result in improved medical student satisfaction when compared with the previous clerkship, which involved a greater emphasis on inpatient service and passive learning experiences.
A total of 91 students (50 males, 41 females) with a mean age of 26.57 years participated in the study. All subjects were completing their required third-year psychiatry clerkship. Forty-seven students completed their clerkship in 1998. These students received a traditional ambulatory experience. Forty-four students completed their clerkship in 1999. This group received the enhanced ambulatory experience. All students completed their clerkship at the University of Michigan Department of Psychiatry, one of several sites offered to University of Michigan medical students. Students were assigned to the University of Michigan site on the basis of student preference and other practical concerns.
There were 47 students placed at the University of Michigan in 1998, the year prior to the new ambulatory program, and 44 placed in 1999, the first year of the enhanced ambulatory clerkship. There were no significant differences between the traditional and the enhanced groups, respectively, in mean age (26.77, 26.35; t=0.68, df=89, P=0.500) or gender distribution (60% male, 50% male; χ=0.842, df=1, P=0.359). Medical school data comparing the traditional and enhanced groups of students, respectively, found no significant differences on the United States Medical Licensing Exam—Step 1 (means: 219.28, 221.30; t=—0.92, df=334, P=0.357) and preadmission Medical College Admission Test scores (means: 10.80, 11.12; t=—1.90, df=252, P=0.059).
Both cohorts (traditional and enhanced groups) completed an end-of-clerkship 37-item questionnaire measuring their satisfaction with the overall psychiatry clerkship, both inpatient and ambulatory. Most items were rated on a 1 to 5 Likert-type scale with 1 indicating poor, 3 indicating good, and 5 indicating excellent levels of student satisfaction. Some questions required students to respond on a scale with 1 indicating strongly disagree, 3 indicating neutral, and 5 indicating strongly agree; and others rated amount of participation on a 1 to 5 scale with 1 indicating too little, 3 indicating just right, and 5 indicating too much.
Student's t-tests were conducted to examine differences in satisfaction between the traditional and enhanced clerkship cohorts. Results are shown in t1.
The mean score on question 9, which rates the overall quality of the ambulatory experience, was significantly higher for the enhanced group exposed to the revised clerkship compared with the traditional group (t=—2.77, df=88, P=0.007). The effect size (ES) for this contrast was moderate to large (ES=0.6). The mean score on question 18, measuring the amount of participation in ambulatory care experiences, was also significantly higher for the enhanced group compared with the traditional group (t=—2.64, df=89, P=0.01). The effect size for this contrast was also moderate to large (ES=0.6).
In an effort to control for type I error, three other items on the student evaluation questionnaire were compared between the traditional and enhanced cohorts. These ratings involved overall satisfaction with the clerkship, both ambulatory and inpatient. No significant differences in overall clarity of expectations for performance (item 2), overall quality of performance feedback (item 11), or overall quality of the clerkship (item 17) were found between the traditional and enhanced cohorts (see t1). Finally, the two groups did not significantly differ in their performance on the National Board of Medical Examiners (NBME) subject exam in psychiatry (t=—1.021, df=89, P=0.301).
We believe an important measure of the success of our new ambulatory program is the student clerkship evaluation, as described above. We hypothesized students who had an active learning experience in an ambulatory setting would rate certain quality measures higher. We specifically predicted that ratings of the overall quality of the ambulatory experience would be higher in the enhanced group versus the traditional group. We also predicted measures of student participation in ambulatory care experience would be higher for the enhanced group. The predicted differences between the two groups on these ambulatory measures did occur at statistically significant levels. Also, effect size for our two key items showed moderate to large differences between the two groups in the desired directions.
In our review of the literature, we did not find similar studies comparing two specific ambulatory teaching methods in the psychiatry core clerkship. Many authors, though, have suggested the importance of using ambulatory psychiatry teaching sites (3,11—13), and the need for educators to provide participatory learning opportunities to medical students (2,12,14,15). Given that the number of medical students entering psychiatry has declined, it is important to improve student attitudes regarding the field of psychiatry (12,16). Exposure to a broad range of practice settings is of critical importance. The results of this study suggest that more exposure to the ambulatory setting increases medical student satisfaction with the psychiatry clerkship. Additionally, students exposed to the enhanced ambulatory experience performed as well on the NBME subject examination in psychiatry as those exposed to the traditional clerkship. This result indicates that students can gain broad-based knowledge of psychiatry through exposure to the ambulatory setting.
One shortcoming of the present study is that we altered both the quantity and the quality of the ambulatory experience. It is not possible to determine whether improved ratings were simply a result of more ambulatory exposure, a higher quality educational program in the ambulatory setting, or a combination of the two. In the traditional year, individual teacher comments and/or ratings were not obtained because of the small amount of time students spent in the ambulatory setting. The comments provided by students exposed to the enhanced experience rated the program favorably. Another factor to consider is differences in personal teaching style of faculty and senior residents between the two years. These can be significant confounding variables when evaluating any programmatic change.
There is a need for replication of the present study by other educators, to ensure that this is a reproducible result. A natural outgrowth of this project would be to develop clerkships based entirely in the ambulatory setting and to compare them with more conventional inpatient-based models. We have received student feedback that the ambulatory experience is the "best part" of the psychiatry clerkship. Although many hurdles are present when doing primary teaching in the ambulatory setting, the results of this study suggest that overcoming these obstacles can improve the educational experience.