In this article, we report on our experiences undertaking necessary reform of psychiatry teaching at Harvard Medical School (HMS) while the medical school was setting the groundwork for the first major overhaul of its curriculum since the New Pathway curriculum was introduced nearly 20 years ago (1). Numerous factors have converged to render medical student education reform a priority at HMS (2), just as such reform is a priority at many medical schools throughout the country (3, 4). Also relevant is the recent call from the Institute of Medicine and influential medical educators for greater emphasis on the behavioral and social sciences in the medical school curriculum (5) and greater integration across neuroscience, neurology, and psychiatry (6). A persuasive argument could have been made in favor of deferring education reform within psychiatry departments until the medical school’s reform initiative had progressed further. Nevertheless, our experiences, as discussed here, suggest several advantages to “getting our own house in order” as a first step to participation as a partner in medical school education reform.
The psychiatry department at our institution is a large decentralized psychiatry program encompassing 10 hospitals that together comprise seven individual departments of psychiatry affiliated with HMS, each with its own chief or Chair who serves on the HMS Psychiatry Executive Committee. Among other activities, these departments sponsor four separate psychiatry residency training programs, three child and adolescent psychiatry training programs, and multiple postresidency clinical and research fellowship programs. The medical school, in turn, is highly decentralized with over 9000 full- and part-time faculty across over a dozen teaching hospitals and institutions, which are fiscally autonomous from the medical school. Although the medical school attracts some of the finest medical students in the country, within the teaching, clinical and research priorities of these institutions, the teaching of medical students has traditionally not ranked high.
As part of a routine review of responsibilities in 2001, the HMS Psychiatry Executive Committee assigned specific areas to each chief, including medical student education, which was placed under the leadership of one of the authors of this article. Upon long overdue review of medical student education, it became apparent that medical education in psychiatry was under-resourced. There was variability of content and quality throughout the preclinical and clinical courses; feedback regarding teaching was inconsistent; communication regarding medical student education among the departmental chiefs or between the departments and the medical school was minimal; department chiefs assigned higher priority to the education of their residents and fellows and were often unaware of their faculty’s specific contributions to medical student teaching; quality of medical student teaching often had no impact on faculty promotion or other incentives; and discussion of overarching educational goals or outcomes was minimal. Moreover, psychiatry had a low profile at the medical school and psychiatric teaching was not well integrated in the curriculum. Following psychiatry’s self-assessment, in 2002 a routine independent medical school review of the 4-week core clerkship described a “lack of enthusiasm, excitement and interest” among students about the field. As many as 75% of students each year were found to delay the psychiatry clerkship until their fourth year, by which time they were distracted by application for residency, and their career decisions and experiences had solidified without adequate exposure to clinical psychiatry. The report on the clerkship also reinforced the findings of psychiatry’s internal review concerning unevenness across and sometimes within the four major clinical sites of the clerkship in didactics, experiences and expectations and lack of continuity with the rest of the curriculum. Despite the contributions of extremely talented and dedicated psychiatric educators, more attention needed to be paid to the medical student teaching mission of the departments of psychiatry.
The HMS Psychiatry Executive Committee decided to proceed directly to a comprehensive reform of psychiatric education rather than to wait on plans for overall HMS education reform. A retreat in the Spring of 2003 brought together all psychiatry faculty who taught medical students, the first such event in more than 20 years. Three working groups were formed (preclinical and clinical curricular groups and administration/finance group). Faculty representatives had a range of experience with medical student teaching and were drawn largely from psychiatry with some representation from other departments and HMS administration and students. The mandate was to take a fresh and critical look at our teaching at all levels to medical students. Each group prepared a summary presented at a follow-up retreat in the Fall of 2003 to the HMS Psychiatry Executive Committee, the dean of the medical school, and the dean of medical education. These summaries provided the blueprint for five task forces (on preclinical, clinical, and integrated teaching experiences; on development of a student interest group; and on a human development curriculum proposal) that formulated specific recommendations implemented in the Summer and Fall of 2004.
A director and associate director of medical student education in psychiatry were appointed in July 2004, following a national search. They serve on the Medical Education Council with three chiefs and work closely with the HMS Psychiatry Executive Committee and faculty. The previous position of director of medical student education was funded largely by one of the psychiatry departments, at which the director also served as departmental director of medical student education, with a small amount of funding from the medical school for the director’s role in leading the preclinical psychopathology course. Funding for the new director and associate director positions is now shared between the individual departments of psychiatry and the medical school. The incumbents are responsible for the overall coordination and leadership of the HMS psychiatry medical student education program. Other individuals have been appointed or have continued as education directors at each of the psychiatry departments.
The introductory psychopathology course for medical and dental students was restructured in mid-2004. Instead of consisting of weekly small group sessions across multiple clinical sites, the curriculum involves every other week 3-hour centralized sessions at the medical school alternating with small group sessions at the individual clinical sites located five to 45 minutes from the medical school. Expert clinicians and clinician scientists known to be outstanding teachers and role models have been recruited to lecture at the centralized sessions. Live or videotaped patient interviews are presented and assigned readings are posted on the medical school intranet site (MyCourses). Sessions are designed to cover clinical features; epidemiology and course of major psychiatric disorders; a summary of treatment approaches; and an introduction to relevant neurobiological, genetic, and other research. Alternate week, small group sessions at the clinical sites allow for group discussion to reinforce the material from the centralized sessions and also involve supervised interviews of patients with disorders discussed in the preceding centralized sessions. To enhance the cohesiveness of the course, site faculty are encouraged to attend the centralized sessions and students are asked to write up a mental status exam on the patient interviews at those sessions for submission to their site preceptors the following week. In addition, the week between the centralized session and site visit, an optional anonymous self-test is posted on the intranet site to highlight the core material and foster group discussion.
The brevity of the 12-week course has involved difficult choices, such as whether to introduce students to personality disorders, eating disorders, somatoform disorders or delirium. Early in the semester, the second-year students formed a psychiatry interest group featuring biweekly lunch talks in which a portion of the material that could not be accommodated within the course could be presented. These talks have proven to be very popular, generating excitement also among first- and second-year students that has helped, we believe, to overcome the low “overt” interest in psychiatry noted by others (7). Whether this will translate into greater interest in psychiatry as a career choice at HMS remains to be seen.
The HMS Psychiatry Executive Committee pressed for a medical school policy revision that was ultimately adopted requiring all students to complete their psychiatry clerkship no later than September of their fourth year. The other 4-week clerkships in the medical school, namely neurology and radiology, soon followed suit. Although the new requirement was regarded as a milestone reinforcing the psychiatry clerkship as a core rotation, a considerable number of exceptions have been allowed by medical school administration. Moreover, along the lines of the “shrinking clerkship” described cogently by others (8), our 4-week clerkship remains an obstacle to accommodating the more ambitious and standardized curriculum and set of educational objectives adopted by the HMS Clerkship Task Force. Decentralized didactic teaching at the clerkship sites has been maintained, pending reevaluation, in order to allow students to maintain a close affiliation with their clinical teams and assigned patients rather than traveling to a central teaching site. A minimum of 6.5 to 8 hours of weekly didactics are now required at each clerkship site. Somewhat more difficult to achieve, a minimum of 2 to 3 hours of weekly individual supervision by a faculty attending is also stipulated. In addition, a consistent weeknight and weekend call requirement has been adopted as well as a uniform requirement for case write-ups. We have also introduced “collaborative assessments,” according to which students at a given clerkship site are given an oral exam by clerkship directors and senior faculty from other sites to facilitate more consistent standards and cross-talk between sites. A standardized assessment scale with anchor points has been implemented for grading. Departmental chiefs have focused more intently on the roles and responsibilities of the clerkship directors within their departments along lines described elsewhere (9, 10). Some, but not all, of the clerkship directors serve as directors of psychiatric education or of medical student education in psychiatry within their respective departments, and many also serve as leaders or faculty within the introductory psychopathology course or in advanced electives.
In an effort to integrate psychiatry teaching into other core rotations, a series of pilot programs have been instituted in the medicine and pediatrics clerkships. These involve either one or more lectures on relevant topics (e.g., managing agitation or delirium, child psychopathology, or “the difficult patient”) or integral participation in psychiatry consults that involve patients on their service. The outcome of these projects has been variable, suggesting that integration is not well achieved in piecemeal fashion and that it requires greater commitment and overarching vision by psychiatry and other departments.
Among the key recommendations of the HMS Preclinical Curriculum Working Group was the reintroduction of a course on human development lacking in the HMS curriculum for over a decade. An ambitious longitudinal course initially proposed by the HMS Human Development Task Force was modified following feedback from the medical school curricular reform leaders. In its current format, the course proposal is for a 10 session multidisciplinary human development course that will dovetail with the second-year courses on psychopathology and neurobiology that follow.
Qualitative feedback from students and from faculty suggests that the changes implemented have been well received. Although the initial driving force of the reform effort was by mandate of the Psychiatry Executive Committee, the sheer number of faculty who have been energized to participate in our internal reform effort has been remarkable. The faculty, in turn, have been gratified by student enthusiasm exemplified by a thriving student interest group that now attracts 40–50 students to its biweekly meetings and a successful student-faculty reception in December 2004 that attracted over 150 participants.
This clearly remains a work in progress. A more systematic and quantitative assessment of these efforts is pending. Nevertheless, a notable outcome is that psychiatry has emerged within the medical school community as a trailblazer in education reform at a crucial time when the medical school has entered the final phases of planning for a new curriculum. Indeed, a number of HMS deans and senior administrators have characterized psychiatry’s reform efforts as a “model” for the rest of the medical school. Psychiatry faculty leaders who have relentlessly addressed deficiencies within our own teaching and countered the undervaluation of psychiatry at the medical school are now recognized by medical school leaders as energetic partners in reform capable of identifying problems, formulating solutions and mobilizing change.
Following a critical self-appraisal of medical student education in psychiatry, which was initially mandated by the chiefs of psychiatry departments affiliated with HMS, psychiatry undertook an extensive reevaluation of psychiatry teaching, which was unprecedented in the history of HMS. Through the diligence of several hundred psychiatry faculty participating in a series of retreats, working groups, and task forces working closely with the medical school, a series of changes has been implemented to allocate necessary resources; improve and harmonize didactics, expectations, and assessments; increase student time with faculty teachers; better integrate clinical and basic science teaching; advance the teaching of human development; and more effectively insinuate psychiatry teaching into other core rotations. In so doing, psychiatry has gained a local reputation as a leader in education reform, a faculty that “has its act together,” and an able partner in the current reform initiative at the medical school. Within an institution that has not traditionally emphasized psychiatry teaching for medical students, much needs to be done to further strengthen psychiatry education. Moreover, further changes in psychiatry education will be necessary and desirable in parallel with restructuring of the entire medical school curriculum more generally. Nevertheless, the steps already taken have encouraged a culture of education reform within the psychiatry departments and have allowed the psychiatry faculty to garner credibility within the medical school as a dedicated and organized group. Both achievements should allow us to participate more effectively in the medical school education reform effort that will likely extend over several more years. Our experiences may be relevant to other psychiatry departments that face the twin challenges of psychiatry education reform and sweeping education reform at their medical school.
The authors thank Jane Neill and Drs. Cynthia Kettyle, Jules Dienstag, Ron Arky, George Thibault, Gordon Strewler, Eugene Beresin, Malcolm Cox, and Joseph Martin, Dean of the Faculty of Medicine, and numerous valued colleagues within the HMS Psychiatry Departments for their integral role in the reform efforts described in this article.
The authors also thank Heather Adams and Linda Messier for editorial assistance.