To the Editor: Psychiatry clerkships are becoming shorter (1). Clinical core clerkships in psychiatry must provide the foundation for understanding and treating serious problems, such as assessing danger to self or others, and using psychiatric medications and other interventions properly. Students learn to appreciate the devastating consequences of chronic and persistent mental illness, as well as the positive impact of psychiatric treatment. No other core clerkship can offer this level of insight into the specialty of psychiatry (2). The National Board of Medical Examiners’ Subject Exam, commonly used as the clerkship final exam, (3), however, is a much broader test of clinical knowledge. It addresses an array of important topics in psychiatry and human behavior that, while essential in medical practice, could not possibly be taught during a short rotation on any one clerkship site.
The ED-2 and ED-8 requirements of the Liaison Committee on Medical Education (LCME) stipulate that clinical placements need to be of comparable quality (www.lcme.org/functions2008jun.pdf). Yet, to allow students to experience “ownership” of their patients, rather than remain passive observers, they may need to stay in distinctly different clinical settings for the duration of a short clerkship. The impact of widely differing clinical experiences on the National Board of Medical Examiners (NBME) shelf exam performance is not known.
Our 4-week clerkship is designed to allow students to experience their patients’ problems in depth, and to integrate into the treatment team. Observational enhancements include child and adolescent psychiatry and ECT. All students share a common core of lectures and teaching conferences. For their clinical work, students remain on one of four clinical sites for the entire 1-month clerkship: an inpatient service at the Veterans’ Medical Center (site 1), a consultation-liaison service at a regional tertiary care hospital (site 2), an acute care public inpatient psychiatric facility (site 3), and an acute care private psychiatric service in a general hospital (site 4).
The shelf exam scores, along with the clinical placement locations, were obtained for 118 third-year medical students who completed the clerkship during a 12-month period. From the total of 118 students, 32% were at site 1, 32% were at site 2, and 27% were at site 3. The remaining 9% were placed at site 4, a private service that often can only accommodate one student per rotation. Besides the descriptive statistics, the univariate analysis of variance was used to determine whether the clinical placement locations affected students’ shelf exam performance. The mean shelf exam scores ranged from a high of 76.64 (SD=8.03) at site 4 to a low of 74.68 (SD=7.42) at site 1. None of the differences among sites were statistically significant (p<0.891).
Regardless of setting, students need to acquire much of their knowledge for the shelf exam from readings, discussions, and other sources. Our data show that this can be done. However, solid shelf exam performance does not ensure that these students actually will recognize more subtle psychiatric issues and psychological conflicts in nonpsychiatric settings. Clinical teaching of the fundamentals of psychiatry requires a full-time core clerkship (2). However, psychiatry educators must transmit knowledge about psychiatric problems throughout the 4-year curriculum (4). Psychiatry and “Human Behavior” content should be further integrated, reinforced, and tested throughout the clinical years, with significant input from psychiatrists and psychologists. Only then can we be assured that our graduates will be able to apply their abstract knowledge to actual clinical situations, regardless of their career choice.
The NBME Step 2 exam is designed to assess the breadth and depth of students’ understanding of clinical medicine, including psychiatry. While separate scores on the psychiatry/human behavior content of Step 2 cannot be obtained, future research should address whether students who excel on the psychiatry shelf exam also excel on the NBME Step 2 CK and CS. This might reassure us that those who do well on the subject exam can actually apply their psychiatry knowledge later on when confronted with clinical problems in nonpsychiatric settings.
At the time of submission, the authors reported no competing interests.