The challenge of integrating psychiatry and general medicine into the core curriculum has long been an educational imperative. In part to address this need via a contemporary educational model, beginning in 2003, the University of California, Davis School of Medicine (UCDSOM) implemented longitudinal courses (emphasizing small group, case-based learning) called “the Doctoring Curriculum” in the first 3 years of the medical doctoral (MD) program. This curriculum and the name “Doctoring” were originally developed in 1990 at the University of California at Los Angeles (UCLA), School of Medicine and were adapted to the UCDSOM milieu. Doctoring continues to be a core component of the UCLA curriculum, and it is being used in 18 others schools of medicine in the United States and internationally (1). The third year course (Doctoring 3) was the first one implemented, followed by Doctoring 2 and 1, respectively, in later academic years. There is also an elective fourth year course (Doctoring 4). All Doctoring courses are described below.
Leadership and Administration
Each course is directed by one course director and two co-directors. A psychiatry faculty member is involved as a director or co-director in Doctoring 1, 2, and 3. Release time for the course directors is provided by dean’s office funding, which is intended to ensure that substantial faculty effort is available for case development, faculty development, and quality assurance. Three Doctoring administrative coordinators are provided by the dean’s office. Additionally, small group faculty who teach more than 50 hours annually are paid a small teaching stipend from the dean’s office, which is intended to compensate for lost clinical income. Course directors and co-directors of all Doctoring courses meet monthly to coordinate curricular material and address issues that impact the curriculum as a whole. The Doctoring course foundation was a consolidation of several previously separate courses taught by psychiatry, internal medicine, family medicine, epidemiology, and ethics in the medical school curriculum.
The initial planning meetings brought together the faculty leaders of these courses to design integrated courses built around established Davis School of Medicine graduation competencies (Table 1
), especially in the domains of professionalism, health care systems, communication, and cultural competency.
Common Features of Doctoring 1, 2, and 3 Small Groups
In Doctoring 1, 2, and 3, groups of 8–10 students are paired with two faculty facilitators (one from psychiatry or other mental health field, and one from another clinical specialty—predominantly internal medicine, pediatrics, and emergency medicine) and participate in 3-hour case based sessions that utilize actors in standardized patient interviewing, a practice that is now common in educational settings (2). Some groups also have a Doctoring 4 student (see “Doctoring 4” section) as an additional facilitator. Group membership remains the same over the course of the academic year. All cases and the embedded standardized patient interviews are developmentally appropriate to the year of medical school.
Prior to each small group case, the course director(s) for Doctoring 1, 2, and 3 run a 1-hour faculty development session which is divided into three portions. Initially, faculty review difficulties and problems from the prior session. This is often facilitated by watching a videotape from one of the small groups. The second portion of the hour is geared toward improving group facilitation skills, and the last portion of the hour is focused on the case that will be delivered later that day. All Doctoring cases are composites of “real” cases based around the clinical experience of the course directors.
After faculty development, the faculty and student groups meet. Each small group session begins with a brief “check-in” where student well-being and reflections on the other Doctoring clinical experiences (and other contemporary medical school experiences) are briefly processed in a safe group format. The use of the group format to discuss student reactions to clinical experiences is similar to a Balint group model (3).
The bulk of the small group session consists of a student interview of the standardized patient, who has been scripted to represent the illness thematically related to that week’s session. Each case is authored so as to raise issues of systemic illness, psychiatric illness, social issues, medical ethics, epidemiology and evidence-based medicine. After the initial part of the interview, the standardized patient is temporarily dismissed while the group then discusses simulated physical examination, imaging studies, laboratory findings, and preassigned readings that are pertinent to the case. Concurrent with the physical examination and laboratory data, data for other variables pertinent to the case (e.g., employment and housing status, insurance status, cultural variables, psychological resistance, barriers to compliance) are included in the database for the group to address. Once the case is discussed and a plan is formulated for how to address the clinical problem, the standardized patient returns for the second part of the interview where the student discusses the clinical plan and arrives at consensus with the standardized patient. Students rotate the interview roles from week to week so that each student interviews once or twice during the academic year. Each Doctoring course has specific learning objectives that are intended to build upon and reinforce those from earlier in the year and across all 4 years of medical school. The specifics of each course are described below.
Doctoring 1 is a yearlong multidisciplinary course spanning the entire first year of medical school. The Doctoring 1 educational objectives are designed to meet graduation competencies of Davis School of Medicine graduates, particularly in developing knowledge and skill in patient care, communication, professionalism, and lifelong learning. In addition to the small groups described in the previous section, traditional lectures, problem-based, case-based, and team-based learning techniques are utilized.
Lectures, large group presentations, and panels provide some of the epidemiology and biostatistics content, specialized areas of physical exam, and selected areas of behavioral science such as human development and human sexuality. Problem-based learning small groups are used to integrate content taught in the concurrent basic science courses with clinical cases. Workshops are used to deliver much of the cultural competency content. Team-based learning is used to teach much of the traditional behavioral science content in theories of human behavior, defense mechanisms, and health behavior change.
The main goals of the course are to develop a foundation in patient-centered interviewing, physical examination skills, cultural competency, behavioral science, human sexuality, statistics, and epidemiology. In addition to the formal learning environments, preceptor visits at various clinical sites and student-run-clinics are required experiences during the course. The subject matter of Doctoring 1 is coordinated to parallel the core curriculum of the first-year basic science courses. For example, physical diagnosis closely parallels anatomy dissection, and problem-based learning cases integrate the organ system under discussion in basic science courses with psychosocial issues in medical care. The psychiatry and behavioral science content in Doctoring 1 is taught primarily in large-group lectures and discussion, team-based learning, and small group clinical sessions.
Nine cases have been designed for small group clinical sessions to develop patient-centered interviewing skills; the cases increase in complexity during the course. Examples of Doctoring 1 cases include a visit for change in primary care physician, follow-up visit following an emergency department encounter for chest pain, and a sex worker presenting with symptoms of a urinary tract infection. The students are videotaped and are able to review their performance.
Doctoring 2 is composed of a series of integrated activities for second-year students. Doctoring 2 small groups meet 14 times in the academic year, and the cases consist of a series of clinical encounters that illustrate clinical-pathological correlations that correspond to other second-year coursework. The interviewing skills required of students are developmentally more advanced than in Doctoring 1. See Table 2
for examples of Doctoring 2 small group cases.
Other clinical activities in the Doctoring 2 curriculum include more advanced problem-based learning small group cases, subspecialty physical diagnosis sessions, high-fidelity simulator sessions, apprenticeships, physical diagnosis preceptorships, and epidemiology discussions. In the problem-based learning groups, the same student groups are used as in the standardized patient interviewing group sessions, but faculty differ. Course integration is achieved by aligning common themes. For example, a preliver transplant patient interviewed in small groups three times during the year will have his medical complications studied in problem-based learning groups, and the ethics of transplantation are reviewed in panel discussion and student mock transplant selection committees.
On the apprenticeships, students experience two types of 3-hour apprenticeships during their second year: an individual experience and rounding on the inpatient wards with a third-year student. Individual apprenticeships include a prison HIV ward, a local county juvenile hall, an outreach program to high risk geriatric patients for in-home assessment, a psychiatric inpatient service, a psychosomatic medicine consultation service, a pregnancy consultation center, the emergency room, and the inpatient nursing service. For the ward rounding experience with third-year students, second-year students rotate on internal medicine, surgery or pediatrics and spend an entire morning as part of the third year student’s ward team.
Doctoring 3 students participate in 23 3-hour sessions and are released from their traditional clerkships approximately every 2 weeks. The check-in portion of each session in the third year is typically longer than in Doctoring 1 and 2, and is highly valued by students who are widely dispersed at various training sites and anxious to share experiences in their incipient clinical care of patients. During this period, students commonly share emotionally difficult experiences encountered on the clerkships, ranging from the challenges of patient care, fitting in to the ward culture, issues related to power, and dilemmas in professionalism. Students also discuss experiences of hope and success. Finally, tips for how to better address challenges of each clerkship are discussed among the group.
Following check-in, facilitators help students prepare for the standardized patient interview, utilizing a highly structured and informative faculty guide. As in the prior doctoring courses, one student interviews the standardized patient as the others observe and give support and feedback. After the standardized patient interview, students debrief and further discuss issues brought up during the interview. Examples of small group cases used in Doctoring 3 are included in Table 3
Doctoring 4 is the only elective year of the Doctoring curriculum. The course is a year-long elective geared toward students interested in developing skills around teaching and learning. Students are selected for this popular course on a competitive basis after submitting a one-page summary explaining their interest in teaching. Doctoring 4 students cofacilitate either a Doctoring 1, 2, or 3 small group with faculty and attend eight evening seminars on teaching. The seminars cover a wide range of topics, and three of these are presented by psychiatry faculty (Table 4
The seminars are highly interactive, with participants sharing their experiences and challenges. In the small group sessions, Doctoring 4 student facilitators apply and practice skills learned in seminar. First-, second-, and third-year students look to them for guidance and reassurance. As group cofacilitators, Doctoring 4 students attend faculty development meetings prior to small group sessions and help in preparation of mid-year and final evaluations and administration of final clinical skills examinations. This window into the faculty world broadens the participants’ perspective. In 2005–2006, 17 students participated in Doctoring 4; of these, four (24%) matched into psychiatry residency programs and one (TM) is a coauthor of this article.
Academic psychiatry has an inherent interest in new models in medical education, not just in psychiatry courses per se, but more “globally” in the education of all new physicians. At University of California Davis School of Medicine, this interest has come to fruition in the Doctoring curriculum. It is the experience of the authors that psychiatry’s leadership and operational roles in these courses offers several tangible benefits.
The role of psychiatry faculty leadership in the design of cases is crucial for the modeling of the biopsychosocial approach. All cases have significant psychiatric content, and/or represent psychiatric illness as the central medical problem. By presenting psychiatric illness as “embedded” into simulated routine clinical encounters, students learn that psychiatric illness is central to medical practice. Presenting psychiatric “content” in clinical scenarios that represent primary care experiences serves to de-mystify and to de-stigmatize psychiatric illness. While we deliberately did not include the major psychiatric illnesses that are relatively less likely to present in primary care (psychotic disorders and bipolar disorders), our specific inclusion of depression, anxiety disorders, suicide, cognitive disorders, substance abuse, and childhood disorders in this curriculum serves to identify these psychiatric problems as among those that should be of interest to all physicians.
The role of the psychiatry faculty in each small group is similarly critical. The psychiatry faculty member’s role in overall management of group process (encouraging balanced participation of all members, containing more extroverted students, and bringing out more introverted ones) is critical as well. These faculty members have been important in the faculty development of the nonpsychiatric facilitators, who are often less experienced in the art of group facilitation. It should also be noted that nonmental health faculty routinely rank faculty development as one of the most valuable parts of teaching in Doctoring, and the area they rank most important is learning from their mental health colleagues—particularly around managing difficult psychosocial issues (4).
The literature on psychiatric faculty involvement in modern educational models in medicine is growing. The Doctoring curriculum incorporates several of the six areas recommended by Rubin and Zorumski (5) for psychiatric leadership in contemporary medical education: integration of psychiatry into the undergraduate medical curricula, presentation of joint instruction between primary care medicine and psychiatry, and presentation of state of the art psychiatric care. An active stance of psychiatry leadership and ownership of academic roles of courses such as ours may be seen as part of an overall effort to constantly update and modernize medical educational offerings; indeed, psychiatry departments have the opportunity to serve as a beacon to other academic medical departments in this area (6). The role of the Chair of Psychiatry at Davis School of Medicine cannot be overemphasized in his support of the many faculty members’ involvement in these courses, as the department has made faculty time availability for these courses a high priority, both by including teaching time devoted to Doctoring into the department’s comprehensive faculty compensation plan and by his own teaching in Doctoring 3 (7). In addition, several psychiatry residents have served as group facilitators, functioning in a faculty role and adding to their own professional development, encouraging nascent interest in the next generation of psychiatric academicians. Parenthetically, the Chair of Internal Medicine has also been a strong supporter of the Doctoring curriculum, making Internal Medicine faculty time available for Doctoring 1, 2, and 3.
The “in-group” psychiatry faculty member helps the students with interview techniques (e.g., the empathic stance, open-ended opening questions, screening for mood disorders and substance abuse, and formal cognitive assessment), points out evidence of psychiatric illness in the cases, assists with organized behavioral observations of the standardized patients, and helps students to integrate the psychiatric factors into the case management and formulation (8–13). The supervised standardized patient interviews also help to prepare students for the United States Medical Licensing Examination, Step 2 Clinical Skills examination. The integration inherent to Doctoring courses has been found elsewhere to change clinical behavior and be of enduring career value for students (14). Specific areas of integration include basic psychiatric skills for all students, structured exposure to the medical-psychiatric “undifferentiated” presentation of cases, and psychiatric skills for primary care bound students (15, 16). Psychiatry leadership may also assist in addressing the issues of mental health systems of care, mental health care disparities, cultural diversity, and culturally competent care (17).
Psychiatry leadership in the Doctoring curriculum presents psychiatry faculty as academic instructors in a highly visible role. This is obviously important in terms of recruitment of students into psychiatry. Students exposed to the stimulating intellectual content and numerous other positive attributes to psychiatry are more likely to consider residency training in psychiatry (18). While attraction to the field of psychiatry and students’ decisions to “match” into psychiatry is a complex decision based on many factors, it is noteworthy that since the implementation of the Doctoring curriculum, Davis School of Medicine matched 13 students (14% of the graduating class) into psychiatry in 2005 and 11 students (12% of the graduating class) into psychiatry in 2006. The 2005 match was the fifth highest such percentage in the United States (19–21). These were the highest psychiatry match rates for Davis School of Medicine in the last 10 years. This is undoubtedly due to several factors, including an active student interest group, a well-regarded second year psychopathology course, a compelling series of highly regarded third-year clinical sites (in a core rotation that has preserved its 8-week duration), and visible psychiatric leadership in several medical school and medical center committees. Nonetheless, psychiatry leadership and participation in Doctoring courses serves to reinforce and perhaps take to a higher level the favorable image of the department already in force. Supporting this hypothesis is the high rate of participation of fourth year students matching in psychiatry in the elective Doctoring 4 program (24% of participants in 2005–2006).
Students have recognized the value and quality of the Doctoring courses in their year end evaluations. For the academic year 2005–2006 (out of 7 maximum Likert-type scale), Doctoring 1 was rated as 5.17 overall. Doctoring 2 was rated as 5.63 overall and Doctoring 3 was rated as 5.79 overall. The net effect of the Doctoring curriculum on specific instructional areas has been reflected in graduation questionnaire survey data. Due to the gradual phase-in of the Doctoring curriculum, the graduating classes of 2004 and 2005 were the first two to participate in the Doctoring curriculum, and these two classes participated in Doctoring 3 only. The graduating class of 2006 was the first to participate in both Doctoring 2 and 3; no class has yet graduated which has participated in all 3 years of Doctoring. While this graduation survey did not address Doctoring courses separately, the implementation of the Doctoring curriculum was the major area of curriculum change affecting the graduates during this period. There is a general trend for students to respond that the curricular time devoted to the areas of patient interviewing skills, physician-patient communication skills, physician-physician communication skills, teamwork with other health professionals, problem solving, clinical reasoning, ethical decision making, and professionalism was less “inadequate” (though, in many cases, more “excessive”) since the Doctoring curriculum was implemented. Given the importance of the clinical skills listed, it is likely better to be slightly “excessive” rather than “inadequate” in such areas. This will continue to be monitored closely as future classes graduate.
Other departments of psychiatry may consider the development of similar integrative courses at their institutions. Presenting students with early, ongoing, and intimate exposure to psychiatry as a clinical discipline, and faculty psychiatrist as professional role models may improve recruitment and development of the specialty.