Providing instruction to medical students on the use and application of psychotherapy is not new. In 1956, Heine developed a program at the University of Chicago School of Medicine to teach students psychotherapeutic skills. In the 1960s, Balint began his group approach, exploring the psychological aspects of patients and their illnesses, with family physicians in England. He then moved to include medical students as well, but did not include supervision of a psychotherapeutic process in ongoing therapy (1). The first program involving junior medical students treating patients in weekly psychotherapy was initiated by Tredgold, Ball, and Wolff in London in 1963 (2). A similar program in Heidelberg was described by Sturgeon and Knauss in 1979 (1).
Frank et al. (3) and Propst et al. (4), at McGill University, described a training program and compared the outcomes of therapies between psychiatrists, psychiatric residents, family practice residents, and third- and fourth-year medical students and found that type of therapist did not affect outcome. An elective program begun in 1995 at the University of Toronto, the therapeutic communication course, allows first-year medical students to provide counseling to a patient over 6 to 18 months while under group supervision (5).
All of these studies involved self-selected students—that is, students who already had an interest in psychiatry. The shortest duration of treatment was 12 sessions, and none of the studies involved patients from the emergency department.
At the University of Toronto Medical School, we thought that providing all clinical clerks with an opportunity to conduct brief crisis-focused psychotherapy would be a useful educational experience. We are training medical students to be "undifferentiated physicians," and we are mindful of the fact that family physicians are often required to help patients cope with life crises. In addition, we are emphasizing the need for students to be active learners rather than passive recipients of knowledge. There is clear evidence that students learn best when learning is contextual (6). In applying these educational principles, the Clerk Crisis Clinic was created to allow students to experience the responsibility that comes with caring for patients independently. The goal was to allow them to treat their own patients over a brief period and to observe the natural evolution of a crisis situation.
The aims of this study were to evaluate the students' and the patients' experience of this crisis intervention.
Every 6 weeks, six third-year clinical clerks from the University of Toronto rotate through the Clarke site of the Centre of Addiction and Mental Health. Thirty-six students are placed at the Clarke site each year (there is a total of 12 weeks during which there are no clerks at the site). During their time at the Clarke site, students spend 3 weeks as part of an inpatient team and 3 weeks in an outpatient department. While in their outpatient rotation, the clerks divide their time between the emergency department, outpatient clinics, consultations with their primary supervisor, and participating in the Clerk Crisis Clinic. At the 3-week point, the clerks switch placements from inpatient to outpatient settings and vice versa. Two students are assigned to the Clarke site from each teaching academy in the University of Toronto system. They may state their preference for where they will have their psychiatry rotation.
The students are unaware that the Clerk Crisis Clinic is part of the Clarke clerkship program when they select their sites. The psychiatry clerkship curriculum is standardized across the teaching hospitals, with small site differences in the delivery of courses. Before 2002, when a site-by-site description was distributed to the preclerkship class, there was no formal means by which they could compare sites. The students may communicate informally with each other about each hospital's strengths and weaknesses, but the students arriving at the Clarke site for their clerkship rotations between 1997 and 2000 seemed to have little awareness of the Clerk Crisis Clinic and their role in it.
The students are assigned to patients on the first day of their outpatient rotation (either week 1 or week 4 of the 6-week block). The patients are preselected from the emergency department population. They are patients who are not thought to be diagnostically complex or in immediate need of psychotropic medication. Clerks cannot prescribe medication, so if medication initiation or adjustment is indicated, the family doctor in the community may need to be involved. Patients may have diagnoses such as adjustment disorder or a major mental illness, but they are assessed initially to have a focus for a brief therapeutic encounter. Patients are told in the emergency department that a senior medical student will provide the therapy under the supervision of the emergency resident or staff. Patients are typically seen within 1—2 weeks of the emergency department referral. Patients are offered this service on a voluntary basis; for those who are not interested in the service, alternative arrangements are made (with a general practitioner in the community or with a social worker affiliated with an alternative hospital crisis clinic).
Clerks are expected to see their patients twice a week over the 3-week outpatient rotation, for a total of six 50-minute sessions. They receive group supervision from a senior resident interested in emergency psychiatry for 2 hours during the week. The resident is available to assess the patient, if necessary, for medication or other problems that may arise. Patients may be on medication during the course of the treatment, but altering the regimen would not be a part of the clerk's focus. The emergency staff psychiatrist is available for backup and supervision.
Before the first session, crisis literature is made available to the students as required reading. They are also provided with a reading about supportive therapy (7) and a number of articles about crisis intervention and supportive therapies. Viederman's Psychodynamic Life Narrative model (8) provides a dynamic template of formulation that the medical students can comprehend. Viederman described a maneuver that was first used to treat depression in the medically ill but is applicable to patients in other situations of crisis. The students learn that patients in crisis tend to regress and with therapy can examine "the trajectory of one's life as it relates to self-perception, to past accomplishments and future hopes and aspirations" (8). The crisis situation provides not only a time of increased vulnerability but also one in which growth is possible in a facilitating environment. The students learn that crisis intervention is possible within a 6-session framework.
Between 1997 and 2000 we administered questionnaires to medical students who completed a rotation at the Clerk Crisis Clinic and to the patients they treated. In this study, we examine the questionnaire responses during that period.
Two questionnaires, one for patients and one for students, were completed at the end of each treatment course and returned anonymously. Student therapists gave their patients a questionnaire after the last session and asked them to complete it and leave it in a designated place in the emergency department.
The patient questionnaire was a modified version of the Consumer Satisfaction Questionnaire (9) containing nine questions that are answered on a 4-point Likert scale. Two questions were included to address the aspect of being treated by a medical student: "Initially, how did you feel about the idea of being treated by a medical student?" and "At this point in time, how do you feel about having been treated by a medical student?" Other questions address overall satisfaction with the clinic, the ability of the clinic to meet the patient's needs, and the patient's willingness to return if necessary.
The clerks completed a therapist evaluation of services questionnaire containing 10 questions that are answered on a 5-point Likert scale. The instrument asks about their feelings, initially and at the end of therapy, about treating patients in crisis. Other questions ask about how relevant they felt the experience was to their training and to their future careers. Clerks were also asked about the effectiveness of the group supervision and the quality of the clinic. Both therapist and patient questionnaires included room for comments.
From 1997 to 2000, 106 clinical clerks completed rotations at the Clarke site and were involved in the Clerk Crisis Clinic. Of these, 103 students had patients; the others joined in group supervision but did not complete questionnaires. Fifty-nine students (56%) completed the questionnaire after the treatment. Of the 103 patients who participated in the program, 41 (40%) completed questionnaires, and most of these completed the treatment. The mean number of treatment sessions was five, with a range of one to seven.
Among patients, 39 (95%) felt that the care had been very good to excellent (t1). Twenty-two patients (54%) reported that initially they had been either indifferent or very dissatisfied about being treated by a medical student. Thirty-nine patients (98%; data missing for one patient) reported that at the end of therapy they were mostly satisfied or very satisfied about being treated by a medical student. Thirty-nine patients (95%) felt that they had been helped a great deal or helped somewhat. Those who did not feel as helped noted that they wanted a longer course of therapy. The majority of patients felt that they had received the help they wanted (95%) and indicated that would return in the future if necessary (88%).
Among the students, 58 (98%) rated the quality of the clinic as good or excellent (t2). Thirty students (51%) reported that initially they were either not confident or definitely not confident about treating patients in crisis, but by the end of the rotation, only 10% were not confident. The students found the group supervision to be quite effective (92%). Indeed, the supervisor was required to assess the patient or observe the student in less than 10% of the cases. The majority of students felt that the clinic had met some to all of their educational needs (93%) and was relevant to their current training (90%).
Naturally, the results of this research must be considered preliminary. We did not use a control group or any pretreatment measures of patient attitudes or other variables. However, the Clerk Crisis Clinic has been well received by both patients and medical students. Patients have been receptive to receiving therapy provided by a senior medical student with supervision by residents or staff. Generally the students assumed the role of therapist with some trepidation initially, but by the end of the treatment with enthusiasm, confidence, and skill.
There are a number of important limitations to this study and to our findings. First, the conclusions are limited by the low response rate of patients and clerks. Having the clerk-therapists distribute the questionnaires may have led to the low response rates; conceivably, patients felt inhibited about answering honestly. Although patient identity was protected during questionnaire collection and analysis, it is possible that patients inflated their satisfaction ratings. However, these concerns notwithstanding, none of the patients who were enrolled in the program sought other means of complaining about or registering discontent with their experience. Thus, we feel fairly confident in our impression of high levels and rates of patient satisfaction.
The response rate among the clerks was also relatively low. This might be attributed to their concern about being critical of a rotation in which they were being evaluated. While clerk questionnaires were also anonymous and were not available to their supervisors before performance grades were assigned, this concern is common among medical students. In addition, the students were expected to hand in their questionnaires independently by the end of the psychiatry rotation. A modification to this approach has been implemented in more recent years to address the low response rate. Now the program administrator meets with the clerks at the end of their rotation to collect all forms; this may improve the student response rate in future studies.
Second, the study was retrospective. Patients' initial feelings about being treated by a medical student may have been more negative than they reported retrospectively at the end of therapy. In addition, it would be important to complement patients' subjective reports of improvement with objective measures of clinical change, such as a pre- and postintervention Global Assessment of Functioning or a structured clinical interview.
Students may have minimized their initial anxiety about providing treatment independently to a patient of their own. It would be of interest to have a comparison group of students who did not take part in the clinic; perhaps those placed at a different teaching hospital could serve as controls.
Concerns have been raised from time to time about the appropriateness of the patient referrals. Having been referred from the emergency department, some patients were unstable and in need of pharmacologic intervention. Occasionally selected patients were diagnostically challenging or had forensic issues that complicated the treatment and were beyond the scope of the medical students' capacity. Some patients were unable to commit to six sessions and did not follow up after one or two meetings. In order to optimize the patient referral process, perhaps the referral base could be broadened to include outpatient departments, family physicians, and consultation-liaison services from the general hospital.
Students have suggested the inclusion of a lecture on the principles of psychotherapy in the second-year curriculum to introduce them to the conceptual framework of psychotherapy.
It would be interesting to follow up with those students who have treated patients in the Clerk Crisis Clinic to see if having done so is related to future career choice and comfort in treating patients in crisis. At this time there is no information on whether the students who have worked in the clinic are more likely to pursue careers in psychiatry. An innovative elective program that has been in operation at the University of Maryland since 1974 has had significant positive effects on recruitment into psychiatry (10). This 4-year program places selected medical students into a special program that focuses on the clinician-patient relationship over the course of the training, offering supervised psychotherapy experiences. The Clerk Crisis Clinic, however, is a much briefer, specialized exposure to emergency department patients and is a mandatory part of the clerkship rotation at the teaching site. Nevertheless, given the positive results of the Maryland program and others, it would be useful to follow up with our students to evaluate the effect this clinical experience had on their career choices.
It would also be useful to follow up with the supervisors who have worked with the students over the years. It has been noted anecdotally that the more comfortable supervisors were with their own psychotherapy and clinical skills, the more highly the students rated them and the better the patients' self-reports were about the success of the treatment. Thus it may be that supervisors' clinical comfort was translated into student therapists' clinical comfort. Finally, a manual for supervisors could be helpful in making this program available in other settings and in standardizing an approach to group supervision at the clinical clerk level of training.
Very few opportunities are provided in undergraduate medical training for students to assume responsibility for their own patients and to provide care in a one-on-one setting. The Clerk Crisis Clinic provides an opportunity for a clinical clerk to be a primary therapist for a patient in crisis. It is apparent from the data in this study that many students achieved a strong therapeutic alliance with their patients over time and began to understand psychodynamic principles such as transference and countertransference that influence all treatment relationships. The clinic provides an arena in which students can integrate knowledge and skills with more independence than the curriculum allows elsewhere.
It appears that patients accept the clinic structure, and those who have used it feel that they have received valuable help. The medical students have benefited from the opportunity to be independent clinicians and to learn to apply basic principles of psychotherapy and crisis intervention. This model of crisis treatment would be appropriate to offer at any medical school with emergency crisis services.