As one of the most recent sponsoring organizations of Academic Psychiatry, the Association of Directors of Medical Student Education in Psychiatry (ADMSEP) is particularly pleased that this special issue of the journal is devoted to medical student education. In comparison with those educational programs that focus on residents and fellows, medical student programs have the task of meeting the needs of large numbers of students, the vast majority of whom do not plan careers in psychiatry. Thus, medical student educators face somewhat different issues than our postgraduate education colleagues. Our students tend to have a number of endearing qualities—youth, energy, idealism—but can also challenge us at times with their immaturity, skepticism, and even disinterest. For those of us who have chosen to devote our careers to medical student education, as many have (1), each passing year provides another—increasingly younger looking—class of students for us to further hone our skills. ADMSEP nourishes and energizes its members in the face of the challenges presented by our students, as well as by the social and economic forces that affect medical education.
The wide range of papers in this issue, selected from a number of wonderful manuscripts submitted in response to our call for papers, contains a fascinating sampling of many of the current issues facing psychiatric medical student educators—from student assessment to innovative curricula to faculty development to recruitment. I believe that it offers something for everyone directly involved in medical student education in psychiatry—from the devoted career medical student educator to the voluntary preceptor. In addition, I hope that my colleagues involved mainly in postgraduate education will have their interest piqued and will consider devoting some time to medical students. After all, medical students represent our future: our future psychiatric colleagues and, even more importantly, our future medical colleagues. Educating them well is a safe investment that will pay high dividends in better care and reduced stigma for psychiatric patients.
The editors and I are delighted that Dr. Herbert Pardes and Dr. Fred Sierles accepted invitations to provide commentaries. Two luminaries in psychiatric education, they present wise historical perspectives on where the field has been and what lies ahead.
Finally, it has been a pleasure working with Dr. Roberts and her highly professional editorial staff. It is a privilege for ADMSEP to join this energetic and insightful group of people devoted to academic psychiatry.
Assessment is a topic of great interest to medical student educators, and it is the focus of three manuscripts. The results of the Briscoe et al. (2) 2003 survey of clerkship directors suggest that improvements in the clinical component of clerkship grades are necessary, since the majority of clinical faculty see grade inflation as a problem and many feel that they can only “occasionally” discriminate appropriately among students. Roman and Trevino (3) present one department’s labor-intensive efforts to tackle the problem—including OSCE (objective standardized clinical examination) video exams and observed patient interviews with evaluation instruments and specific grading criteria—and the results are concrete and striking: while initially more than 60% of their students received the equivalent of an “A,” only 15% of students receive an “A” equivalent postreform, and, perhaps more importantly, faculty feel that clinical skills are evaluated more objectively and students in need of remediation are identified more reliably. Another means of addressing grade inflation is the use of standardized tests: student performance on the National Board of Medical Examiners (NBME) Subject Test is increasingly being used by clerkship directors to determine a significant portion of the overall clerkship grade (4). Manley and Heiss (5) recommend against such use, instead viewing the Subject Test as a “barrier exam,” i.e., beyond a minimal passing score, examination performance should not affect the overall grade. They base their recommendation on the results of their study, which found that students taking the psychiatry examination near the end of their clerkship sequence had a small but statistically significant higher score, although no particular preceding clerkship was more likely to result in an increased score.
Sometimes curricular innovations are useful to keep faculty, including course directors, interested and enthused. Ideally, such changes should also address an identified area of need, and that is the case in the three manuscripts included here (6, 7, 8). These courses are particularly appealing in that they attempt to integrate psychiatric knowledge and skills within a more general medical context. Halperin (6) describes a successful seminar-based course intended to flesh out the students’ exposure to the less severe psychopathology that they will be likely to see in their own medical practices. The course covers psychosocial assessment of medical patients, including mood disorders, management issues in personality disordered patients, and the practical implications of psychodynamics in physician and patient communications, among a number of topics. An impressive 85% of students felt that the course was useful. Dunstone (7) is of interest for both its content—the application of neuroscience to clinical psychiatric problems—and its method—essentially a cyberspace version of problem-based learning, which could be adapted to other subjects and would be especially useful for medical schools with clerkship sites that are not geographically contiguous. Both Halperin and Dunstone provide sufficient detail that readers could recreate similar curricula at their own schools. Alpert et al. (8) provide a blueprint for a broad psychiatric curriculum restructuring. Proactively anticipating school-wide changes, they are particularly attentive to their department’s reputation within the larger medical school context. Given that our medical students spend most of their time with faculty from other departments, their noninsular approach makes good sense and should serve as an important example for us all.
Pessar and colleagues (9) address the important issue of faculty development and make a number of useful suggestions to enhance faculty recruitment, including encouraging departmental chairs to serve as role models and enforcing the requirement that voluntary faculty teach, as well as to improve faculty satisfaction, including rewarding good teachers with awards, academic promotion, and participation in teaching academies. McIlwrick et al. (10) will be of particular interest to course directors responsible for ensuring that appropriate feedback is given to medical students, which has become a recent focus of the Liaison Committee on Medical Education’s (LCME’s) accreditation process. The authors represent a range of positions, from medical student to psychiatric resident to attending, thus providing a broad perspective on the persistent problems of vague and unfocused feedback. They insightfully raise an important question that requires further exploration: since many strategies and tools exist for providing appropriate feedback, why do faculty and residents continue to perform so badly in this area?
Three manuscripts are devoted to the topic of student characteristics and attitudes, and the related subject of recruitment into psychiatry. Both Neidermier (11) and Cutler et al. (12) reassuringly find that students regard many aspects of psychiatry favorably, even though the overwhelming majority of students do not choose to pursue it in residency. Vaidya et al. (13) counter concerns that have been raised about international medical graduates who are pursuing psychiatry as a second choice, reporting that international and U.S. medical graduates training in psychiatry do not differ on standardized personality measures.
The topic of learning objectives is covered thoroughly from two perspectives: Brodkey et al. (14) describe their current use by psychiatric faculty teaching medical students, and Burke and Brodkey (15) place that use in the broader context of all of the core clinical clerkships. Among Drs. Burke and Brodkey’s most interesting recommendations is that ADMSEP should develop a set of clinical case problems linked to specific learning objectives, which could be made widely available to psychiatric educators.
In sum, I hope you’ll agree that the papers presented in this Special Issue of Academic Psychiatry offer, as promised, a number of challenges—some accompanied by solutions, many others awaiting further work. Enjoy!