Child and adolescent psychiatry (CAP) continues to have a severe practitioner shortage. One recruitment strategy has been to explore methods to enhance medical student CAP exposure to increase interest and CAP career choice (1–4). There is general agreement that CAP is important in the undergraduate curricula. Some key features are having early medical student exposure, clinical experiences, and interesting clinical and research opportunities. Other essential elements include child/adolescent psychiatrists participating in other aspects of the medical school curricula and providing mentoring and role modeling for students. The literature indicates that more beginning psychiatric residents indicate an interest in CAP than enter the field (5–9). The literature on student CAP teaching primarily addresses undergraduate CAP teaching approaches, topics, and experiences; opinions about the importance of CAP in the curricula; and strategies to increase student interest (10–30). Despite the interest in this approach, there is no national current overview of the existing CAP curricula for medical students in the United States and Canada. Prior surveys indicate that CAP teaching comprises a small percentage of the curricula. Child and adolescent psychiatry was 0%–10% of the psychiatric curricula in about one-quarter of the schools in 1976 (31), and 24.2% of students rotated on inpatient CAP rotations in 1991–1992 (32). In 1986, all Canadian schools had CAP didactics and most had some clinical experiences (33). Investigators have found comparable information on CAP undergraduate medical teaching in other countries (34–40).
Understanding current CAP teaching in medical schools is essential to provide a foundation and baseline for present and future CAP education initiatives. Since the last surveys were done in the United States and Canada, medical school curricula have changed significantly, with additional knowledge requirements, interdisciplinary teaching, early integration of clinical care, and scholarly activity requirements. It would also be helpful to have current data on the relationships between student CAP interest and the various factors thought to be relevant. This project surveyed the medical schools in the United States (N=125) and Canada (N=17) accredited by the Liaison Committee on Medical Education (LCME) to obtain data on current CAP teaching and to assess some variables considered to be important in developing and maintaining CAP student interest.
The Emory University institutional review board (IRB) reviewed the study and concluded that it was not clinical research and therefore did not require IRB approval. The medical schools were identified from the Association of American Medical Colleges (AAMC) website and the course directors from the schools’ websites. The survey went to the medical student education directors. The directors were chosen as the contact individuals because they can be reasonably expected to know the content of the psychiatry curricula and the interests of the students choosing psychiatry. If there was no identified overall director, surveys were sent to course and clerkship directors. If no one could be identified, colleagues at the institution were asked for contact information. The survey was not anonymous to allow follow-up; the requested data were public and not sensitive. I e-mailed each course director a description of the survey, its purpose, and an attached survey. Respondents were asked to clarify any conflicting information or answer any incomplete sections of the survey; most responded to these requests. Reminders were sent to nonresponders. The surveys were distributed and collected from spring through fall in 2006.
I developed the survey based on information from the literature in consultation with CAP colleagues. The questionnaire asked about the extent and content of each school’s CAP undergraduate curricula, the estimated average number of students per year matching into psychiatry who expressed interest in CAP, CAP leadership (if child and adolescent psychiatrists had medical school administration or medical student education leadership positions), the respondent’s opinion about the importance of CAP teaching in the preclinical and clinical years, and the types of preclinical and clinical experiences as well as the timing of activities and whether they were required. The survey used a checklist format to encourage completion with space to add additional comments. It is available upon request.
The results were analyzed to determine if there were any statistically significant associations between the CAP student interest and various program characteristics. Using SPSS 17 (2008), the continuous variables were analyzed with t tests, the categorical data with chi square tests, and the ordinal variables with a correlation analysis. All analyses used a 95% confidence interval (95% CI) and all significance levels are two-tailed. Program characteristics were grouped according to three factors considered to be important in cultivating medical student CAP interest: CAP leadership, early exposure, and clinical experiences. Child and adolescent psychiatry leadership was defined as present if a child and adolescent psychiatrist was a medical school administrator or medical student psychiatry director (CAP director). The importance of teaching CAP also was classified as a leadership characteristic. It was decided that preclinical CAP experiences could represent early exposure since this material is taught during the first 2 years of medical school. Preclinical and clinical CAP experiences were considered present if there were didactics, if they were required, or if electives were offered. Child and adolescent psychiatry rotation was included as a clinical experience.
Of the 142 schools, 115 returned the survey. The surveys appeared to be completed by directors, associate directors, and course directors (n=95, 76.6%); their assistants (n=8, 6.5%), child and adolescent psychiatrists teaching the students (n=11, 8.9%); or administrators responsible for departmental psychiatric education (n=1, 0.8%). A number of surveys were incomplete, with most missing data for the subcategories of questions asking for amounts (i.e., class hours, student numbers). Blank or “do not know” answers were coded as missing. Data are presented in frequencies and percentages; when appropriate, averages, medians, and ranges are reported. If respondents gave a range, an average was calculated and used in the analysis. If the number of students participating equaled the class size, the experience was classified as required. One school reported a 16.6% CAP interest which was not included in the analysis because it exceeded the interest reported in psychiatry. It is possible that the respondent was including individuals who were interested in CAP but not psychiatry. The rest of the data from this survey was included since most of the questions were on the typical components of CAP curricula and were less likely to be misinterpreted.
Table 1 provides information on students and programs. Almost 45% of those matching into psychiatry were interested in CAP. Approximately one-third of the programs had some form of CAP leadership. Several psychiatry interest groups had significant CAP focus and involvement. The majority of the respondents thought that teaching CAP was important or very important.
Information on CAP didactic curricula content and instruction methods is in Table 2. Most of the schools that taught preclinical CAP didactics (95%) required students to attend the classes. The average number of hours of instruction was 7.4, with a range of 1–30 hours. In addition to the topics in Table 2, subjects included chronic illness, compliance, consultation-liaison, culture, and ethics. Most of the classes were lectures. Additional comments indicated that CAP was integrated into other preclinical curricula, offered as a focus for a neuroscience minor, an option for the doctor-patient course, included as cases in the problem-based learning curricula, and offered as a student run elective. Several schools offered preclinical electives in basic and clinical research. Most schools (93.5%) required CAP didactics during the clinical years, also taught primarily through lectures. The average number of hours of clinical class was 4.3, with a range of 1 to 35 hours. In addition to the subjects listed in Table 2, other subjects included community, emergency, military, facilities, and pathophysiology. The topics taught were similar for most schools, and most covered quite a few subjects in a limited number of hours.
Data on CAP clinical experiences are listed in Table 3. Seventy schools (62.5%) provided clinical CAP rotations for the students, with only 25.7% requiring it. Data on CAP rotations was reported by 110 schools; an overall average of 23.4% of students participated. In addition to the activities listed in Table 3, experiences included an infant-toddler clinic, a developmental disabilities school, emergency service, and a pediatric clinic. Most schools offered clinical electives. The average number of electives was 2.1 with a range of 1–6. On average, 4.8% of students took clinical electives (range=0–28.6%). Opportunities other than those listed in Table 3 included community, developmental disabilities, eating disorders, emergency, family law, forensics, foster care, infant-toddler clinic, independent practice, research, residential, substance abuse, sexual offenders, subinternship, CAP-related 4th-year thesis, and electives tailored to student interest.
None of the selected variables (CAP leadership, preclinical, and clinical experiences) had statistically significant associations with CAP interest. I examined the activities thought to support CAP interest to see if certain CAP experiences were more likely to occur if certain program characteristics existed. Having CAP leadership—either a CAP director or medical school administrator—increased the likelihood of a special interest group (either psychiatry or CAP; χ2=7.6, df=1, p<0.006, n=112), a clinical rotation (χ2=8.3, df=1, p<0.004, n=112), and more students participating in clinical electives (t=−2.8, df=85, p<0.006). The importance of teaching preclinical CAP was positively correlated with CAP being taught clinically (r=0.243, df=102, p<0.05), clinical CAP didactic hours (r=0.230, df=91, p<0.05), presence of CAP clinical rotation (r=0.243, df=102, p<0.05), and students taking clinical electives (r=0.286, df=90, p<0.01). The importance of teaching clinical CAP was positively associated with having clinical electives (r=0.342, df=82, p<0.01). Preclinical didactics were associated with clinical classes being taught (χ2=7.9, df=1, p<0.005, n=111), having preclinical electives (χ2=10.3, df=1, p<0.001, n=113), and having CAP residents work with students (χ2=7.8, df=1, p<0.005, n=110). Required preclinical didactics were positively related to preclinical class hours (t=−3.1, df=92, p<0.002), clinical classes being taught (χ2=7.5, df=1, p<0.006, n=107), having clinical electives (χ2=9.7, df=1, p<0.002, n=108), and CAP residents working with students (χ2=7.6, df=1, p<0.006, n=105). Having a CAP rotation was positively associated with having a CAP residency (χ2=11, df=1, p<0.001, n=112). The presence of clinical electives was positively related to CAP residents working with students (χ2=10.6, df=1, p<0.001, n=110).
The approach of identifying and examining the possible individual factors that influence CAP interest is a logical first step. However, it may be unrealistic to expect significant associations since it is likely that the influences that impact student CAP interest are interactive and additive. To examine this hypothesis, I decided to look at several of the key variables together. Leadership variables (CAP director, medical school administrator, respondent opinion of importance), preclinical didactics, and clinical experiences (CAP rotations, clinical electives) were combined into groups with factor(s) from either all three categories or two of the three classifications. These pooled factors were then analyzed to see if there were any significant relationships between particular groupings and CAP interest or specific program characteristics. None of these groupings demonstrated any significant relationships with CAP interest. Some combinations of CAP leadership and other variables had significant relationships with particular program factors. Having CAP leadership and a CAP rotation was positively associated with the number of students participating in clinical rotations (t=−3.5, df=93, p<0.001). Having a CAP director, preclinical CAP didactics, and a CAP rotation were positively associated with students participating in clinical rotations (t=−3.1, df=93, p<0.002), having a medical school administrator (χ2=11.7, df=1, p<0.001, n=112), and having a special interest group (χ2=10.1, df=1, p<0.002, n=112).
These analyses were done comparing the U.S. schools with the Canadian ones; there were no significant differences. The schools with the lowest rates of CAP interest (10 schools, rates of 0 to 0.9%) were compared with the schools with the highest rates (nine schools, rates of 4 to 7.5%). No comparisons between these two groups were statistically significant, though the higher CAP interest group had higher rates of students participating in CAP rotations (mean of 36.8% versus 16.6%).
Respondents commented on the difficulties in providing CAP teaching for students due to limited resources and time, scheduling constraints, and CAP faculty unavailability. Additional remarks were that it was difficult for the CAP residents to work with the students due to resident scheduling, that student exposure was observational due to time constraints, that more students expressed interest than could participate in CAP experiences during their clerkship, and that some students expressing a CAP interest developed other psychiatric interests. While not asked about their level of satisfaction with the curricula, a number commented on the frustrations related to CAP and psychiatry generally due to limited time, competing demands within the medical school, and limited resources.
Information on Web-Based Resources
Comparisons of the school web pages were very informative. A number of schools had pages that were easy to navigate, not restricted, and had readily accessible information on CAP undergraduate teaching, the division, faculty, and residency. Several included additional information on CAP topics, local organizations and activities, educational resources, available student awards/opportunities, and links to relevant organizations (e.g., AACAP). Other schools had quite limited information which was difficult to find, though their students may have access to non public pages. These sites tended not to have links between their CAP division and student teaching pages and also did not provide information on CAP resources. For some schools, it was difficult to determine who was responsible for or involved in CAP undergraduate teaching.
This project obtained data on CAP teaching for medical students at U.S. and Canadian medical schools. The overwhelming majority of students receive limited CAP didactic teaching, with approximately 24% of students experiencing a clinical CAP rotation. One-third of the schools have child and adolescent psychiatrists in leadership positions. Most survey respondents thought teaching CAP was important or very important. I hypothesized that the factors relevant to CAP interest were CAP leadership, preclinical didactics (early exposure), and clinical experiences; however, none of these, when analyzed as isolated factors or in combination, had statistically significant relationships with CAP interest. Some variables and combined factors had statistically significant associations with program characteristics. The analyses support the idea that certain program characteristics may facilitate the availability of CAP experiences and student participation. Comparing the schools with the highest and lowest CAP student interests did not yield statistically significant associations, but the highest group had notably more students participating in CAP rotations than the lowest group did.
Strengths of this study include the high survey response rate, with data provided for most questions. It obtained enough information to provide an overview of CAP teaching in U.S. and Canadian medical schools. Additionally, data were acquired on a range of factors that could influence student CAP interest and participation in CAP activities.
There are a number of limitations of the data. The survey was designed to minimize respondent burden so the content was limited and the format did not require much detail. The survey did not gather information about content or structure of specific experiences; the quality and effectiveness of teaching; or important educator characteristics. Some respondents may have had difficulty answering the questions because their curricula structure did not match the survey outline. Definitions were not provided, so answers may reflect differing interpretations of the questions. The survey did not obtain information on CAP taught outside of psychiatry.
The data were not objective and may not accurately reflect the director’s opinion about the importance of CAP since a number of the forms were completed by other individuals. The data about students matching in psychiatry and interest in CAP reflect the respondent’s estimate of the recent student class average, which may not be consistent year to year. The directors may not have been the best source of information for student interest. The surveys were not anonymous and some individuals may have inflated their report of the value of CAP. Finally, the data from this survey provides a snapshot of CAP medical student education in 2006 and may no longer be accurate for some of the participating institutions.
The results indicate that the amount of CAP teaching for American and Canadian medical students appears to be comparable to what has been previously found (31–33) as well as to information from other countries (34–40). Most students have limited exposure to CAP in the form of didactics, with schools generally comparable in the amount, content, format, and timing. Approximately 23% of students have CAP clinical exposure during their psychiatry clerkships with the minority of schools requiring CAP experiences. Most schools have elective opportunities for mostly 4th-year medical students with a small percentage of participants. Schools appear to offer similar clinical rotations. Many students matching into psychiatry express an interest in CAP, supporting the contention that there are students who are potential child and adolescent psychiatrists for whom earlier and more innovative outreach efforts may be effective. Also, there may be additional students who have an interest in CAP but not psychiatry. This information should provide a baseline to plan educational and advocacy efforts, as well as data to assist with where and when in medical school to target these efforts. Further research could explore the impact of specific CAP activities such as mentoring, preceptorships, research opportunities, specialty tracks, awards, and grants as well as looking at what is taught in pediatrics and the role of pediatricians.
These survey results may indicate that early exposure and clinical opportunities may be effective strategies to engage students that most schools could provide as part of clerkships and didactics. The survey did not obtain much detail on clinical experiences, but based on survey comments, many were brief. These experiences may not adequately teach CAP content and skills but may be enough to maintain or develop student interest.
The American Academy of Child and Adolescent Psychiatry (AACAP) has initiatives to provide opportunities for students such as providing information on elective activities, attending the AACAP annual meeting, doing clinical work or research with child and adolescent psychiatrists, or attending career nights. The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) and APA have CAP information for medical students and opportunities to participate in various psychiatric activities, including CAP. It may be productive to broaden these funded activities to provide as many options as possible throughout medical school for students at their own schools or elsewhere; even brief activities may be beneficial. Expansion of such opportunities to include CAP faculty awards could provide specific funding for faculty time and other resources to provide clinical activities, projects, research, and mentoring for students. Projects could have reporting and outcome data requirements. This approach also could provide support and external recognition for CAP faculty for educational endeavors with students, which often is difficult to obtain. These organizations also could spearhead and support a coordinated effort to develop and disseminate key CAP content and resources to help schools and CAP divisions provide appropriate and accessible information, opportunities, and resources for students in their programs and on their websites.
Thanks to all of the survey respondents for their participation. Beth Adams and Marianne Celano, Ph.D., are much appreciated for all of their invaluable assistance as well as all those associated with the AACAP Harvard Macy Scholars Program. Dr. Dingle has received Honoraria ($750–$1,000) for representing APA at educational meetings and for USMLE exam participation.