United States medical students are required to complete a psychiatry clerkship during their clinical training, but the structure and content of clerkships vary considerably among medical schools. The Association of Directors of Medical Student Education in Psychiatry (ADMSEP) has adopted a position statement on length of the psychiatry clerkship (1), recommending at least 6 weeks; however, this position is not uniformly adopted nationwide. In fact, psychiatry clerkships typically vary from 4 to 8 weeks (2, 3), with the preclinical exposure of students to psychiatry also widely divergent among medical schools (4).
At the same time, outcomes of medical students, as assessed by performance and competence on national examinations, are central forces in curriculum design. Many psychiatry departments have already incorporated the National Board of Medical Examiners’ (NBME) Psychiatry Subject Examination. Students are required to successfully complete United States Medical Licensure Examination (USMLE) Step 2 CK, which includes psychiatry and mental disorders subtests. In addition, USMLE Step 2 CS comprises stations assessing the communication and clinical abilities of students; acquiring these skills are fundamental goals of psychiatry clerkships.
Existing research demonstrates that clerkship length and timing may or may not affect performance on nationally standardized examinations. Data once suggested that students who participated in longer psychiatry clerkships tended to have higher scores on the NBME Psychiatry Subject Test (5). More recently, data from the NBME regarding the 2007–2008 academic year indicated that students participating in 5- or 6-week psychiatric rotations tended to have higher total test means on the Psychiatry Subject Examination (6). Indeed, challenges and obligations of clerkship directors include the design and implementation of a suitable educational curriculum given the constraints of clerkship duration, faculty and facility resources, and hosts of other considerations.
Hence, we examined how our academic medical center addressed the multiple challenges inherent with designing an experience that would be efficient and practical for students during their 4-week psychiatry clerkship while providing optimal educational outcomes and suitable clinical experiences. The study builds on our earlier work (7) addressing student attitudes, curriculum, and test performance. The goals and purposes of this project included implementing a revised curriculum for third-year medical students that would adequately prepare them to be physicians and determining how this newer curriculum affected performance on the USMLE Step 2 CK and NBME Psychiatry Subject Examinations.
The study was completed within the Department of Psychiatry at Ohio State University. Approval from the institutional review board was obtained to conduct this study during the academic years 2004–2006. The new curriculum was implemented at the beginning of the 2004–2005 academic year. There were 414 students eligible to participate in the study; 405 total students (98%) were enrolled. An introductory meeting explaining the nature of the research project was conducted monthly, at the beginning of each clerkship rotation. Participation in the surveys at the beginning and end of the clerkship was voluntary and required formal written consent. The students’ participation status in the study was not revealed to supervising faculty members or the grading committee.
To fulfill the neuropsychiatry clerkship requirement, students spend 4 weeks rotating on psychiatry services and 4 more weeks rotating on neurology services. Throughout the 8 weeks, students attend joint lectures and a clinical skills session that encompasses both disciplines, but most clinical and educational experiences are distinct.
Historically, the clerkship included 8 weeks exclusively in psychiatry. The psychiatry clerkship was reduced to 4 weeks in academic year 1998–1999. During this time, inconsistencies were evident in the students’ class performance on USMLE Step 2 CK, as indicated in Figure 1.
The psychiatry clerkship formerly contained a departmentally derived examination rather than the NBME Psychiatry Subject Examination. The NBME examination was implemented in academic year 2004–2005 as part of the department’s overhaul of clerkship components. Although this exam offers objective feedback about clerkship effectiveness, the timing of its implementation—during the study period and without prestudy comparison data—limits its utility as an outcome measure.
Our study evolved from previously published findings regarding student perceptions about psychiatry and the existing psychiatric curriculum at the medical school (7). Limitations of the previous curriculum were that students’ clinical exposure over the 4-week clerkship varied widely between rotation experiences, and some didactics were not encompassing. The goal of the new curriculum was to ensure that, regardless of clinical rotation site, students would have a minimum exposure to major, relevant topics in psychiatry that would be clinically useful regardless of students’ ultimate specialty choice.
Given the constraints of a 4-week clerkship, a high-density and high-yield approach toward the educational division’s goal was desired. The need was evident to provide greater, more inclusive education on major topics in psychiatry such as mood, psychotic, anxiety, and substance-related disorders and to aptly prepare students for examinations such as the NBME Psychiatry Subject Examination and the psychiatry and mental disorders sections of USMLE Step 2 CK.
Before the initiation of the newer curriculum, students spent approximately 3 hours weekly in classroom instruction (lectures). The time allotted to education was doubled to more than 6 hours weekly of clinically focused modules consisting of interactive lectures and group discussions of preassigned topics, clinical scenarios, and quiz reviews. The content of existing lectures was expanded, while the quiz reviews were a strategic addition. Finally, the NBME Psychiatry Subject Examination was administered to all students in place of the departmental examination.
To enhance the clinical experience and provide students with supplemental learning opportunities, a clinical exercise focusing on interviewing skills was implemented. Students were also required to submit a complete patient history and mental status and physical examinations for formal review and comment, participate in a predetermined number of encounters with patients having various psychiatric conditions, and observe ECT.
The College of Medicine compiles data on class performance on USMLE Step 2 CK relative to the national average, including score distribution of first-time test takers on subtests representing medical disciplines and organ systems. Similarly, class performance on the NBME Psychiatry Subject Examination is compared to national statistics.
These statistics are presented in standard score (Z-score) units and represent the class mean for first-time takers. A Z-score of 0 indicates that the College and NBME national means are equivalent. A positive Z-score indicates that the College mean is higher than the national mean, while a negative Z-score indicates that the College mean is lower than the national mean. Of note, first-time takers complete the USMLE Step 2 CK approximately within the year following completion of the psychiatry clerkship. For instance, data from the 2006 testing administration includes students who completed the psychiatry clerkship during the 2004–2005 academic year.
We reviewed scores on the psychiatry and mental disorders subtests of USMLE Step 2 CK. Annual Z-scores demonstrate a significant increase beginning in 2006, correlating with the implementation of the new curriculum, as indicated by the arrow, during the 2004–2005 academic year (Figure 1). Further, the progress in student performance is maintained in subsequent testing cycles, during which the newer curriculum has remained in place.
Class performance on the NBME Psychiatry Subject Examination was examined relative to national means and is illustrated in Figure 2.
The above-average performance by our students compared to students nationally on two measures suggests that the 4-week educational experience is yielding positive trends. Perhaps one must remain concerned about the constraints of a 4-week psychiatry clerkship and realize that clinical exposure to the broad diversity of human interactions that comprises psychiatry could be compromised at the expense of examination performance.
The overriding goal of the revised curriculum was to adequately and efficiently prepare students to address fundamental clinical challenges that they would later encounter as physicians, not to achieve high test scores. Indeed, more recent efforts are focusing on refining and improving students’ clinical skills through various patient-centered simulations. Additionally, results of student satisfaction surveys with the curriculum suggest that goals are being met to have a curriculum that is intellectually stimulating, relevant, and desirable to students.
Nonetheless, existing research suggests that examination performance may be adversely affected or, at a minimum, unaffected by clerkship length (2, 5). This study demonstrates, from a clinical knowledge and class perspective, that above-average performance can be accomplished with a clerkship of 4 weeks. Indeed, evolving knowledge, responsibilities, and constraints that emerge in medicine challenge psychiatric educators to keep pace without sacrificing clinically prudent and comprehensive educational goals. Further work is underway to examine the sustainability of these results and the effect of structured clinical interviewing experiences on educational outcomes.
This study has limitations, including the lack of a comparison group. It would have been useful to have NBME Psychiatry Subject Examination scores for classes before academic year 2004–2005, because we cannot completely discern if scores are attributable to curriculum revisions, represent baseline performance, or are influenced by other factors. One could hypothesize that perhaps USMLE Step 2 scores were elevated as a direct result of the incorporation of the NBME Psychiatry Subject Examination rather than the combination of educational initiatives that were implemented. Internal data support that the departmental clerkship examination correlated positively with performance on USMLE Step 2, until the clerkship duration was reduced from 8 to 4 weeks.
Additionally, because class data consists of first-time test takers, a small number of students included in the analysis may have delayed taking examinations or the clerkship, which could modify results. These numbers are likely small, perhaps five students per academic year. Also, fewer than 10 students annually fail the examination, regardless of implemented curriculum or subject versus departmental examination. This would suggest that student motivation and other external factors can influence results.
Similarly, one must consider the actual influence of the scholarly activity on student perceptions and outcomes. That is, reliance of the study on student participation may underscore learning objectives for the clerkship and influence results. This raises the intriguing question of whether the results are sustainable beyond the conclusion of the study period. It is also possible that students may receive greater reinforcement of psychiatry subject content during other clerkship rotations. This could contribute to the favorable results and diminish gains attributable to changes in the clerkship curriculum.
At the time of submission, the authors reported no competing interests.