In the University of Michigan’s Department of Psychiatry, ways to utilize problem-based learning in order to provide consistency during the third-year medical student clerkship have been devised. In particular, self-study problems to help train medical students in emergency psychiatry have been developed. Emergency psychiatry services serve a key role in educating residents in psychiatry and, to a more limited extent, medical students. In psychiatric emergency training, residents and students learn about acute management of psychiatric problems, particularly agitation, suicidal and homicidal ideation, substance abuse, and acute presentation of patients with depression, schizophrenia, and bipolar disorder (1). Ideally, residents and students should learn emergency psychiatry through a well-designed rotation (2). But while residency programs can provide an emergency psychiatry rotation, it is often not possible to provide medical students with a comprehensive (or even adequate) emergency psychiatry experience in addition to their other psychiatry experiences within a 4- to 6-week clerkship. Alternative ways are needed to allow students to learn key concepts in emergency psychiatry. Independent studies of cases in emergency psychiatry are one way to accomplish this task.

At the University of Michigan, third-year medical students have a required 4-week clerkship in psychiatry. During that time, they are assigned to one type of setting (inpatient, consultation, or community mental health) at one of several different hospitals (University of Michigan, Ann Arbor Veterans’, Saint Joseph Mercy, or Chelsea). All students spend some time in an ambulatory setting. Students who have their primary assignment at the University of Michigan or the Veterans’ Hospital spend time in the psychiatric emergency services at the University of Michigan, but the time is limited and their experience is not uniform. Students rotating at the other hospitals have a variable exposure to emergency psychiatry. The psychiatric emergency services facility at the University of Michigan is the only dedicated psychiatric emergency facility in the county (other hospitals have psychiatric emergencies evaluated through the general emergency department). Most of the students attend one didactic lecture in emergency psychiatry which reviews important concepts in behavioral emergency management. Despite an effort to provide students with a well-rounded and inclusive psychiatry clerkship experience, some students complete the rotation without extensive clinical experiences in emergency psychiatry due to the external constraints of time, location, and patient flow during the clerkship.

To supplement their clinical experiences, students in the last 2 years have been given self-study cases in emergency psychiatry. A series of five cases were developed by the authors around a series of important emergency clinical issues: suicidal ideation, agitation, medical illness in a psychiatric patient, and alcohol intoxication. Each case began with a one to two paragraph vignette, followed by a multiple-choice question about the next step. The cases included four to five questions that the students could answer for themselves, although the flow of the case presumed a specific answer (not always the correct one) (a1). At the end of each case, the students were given a discussion of the different answers and the implications of choosing a particular plan of action. To assess whether these cases resulted in improved awareness of emergency psychiatry, a group of students was assessed on key skills in emergency psychiatry issues before and after their psychiatry rotation.

Assessment was completed on one-half of the University of Michigan medical students who rotated through psychiatry during the academic year 2000—2001 (N=81). On the first day of the rotation, students were given a four—question pretest on key skills in emergency psychiatry. These four questions tested critical skills for psychiatric emergency management, such as suicide assessment, management of an intoxicated patient, appropriate screening for psychiatric hospitalization, and appropriate safety measures. The students were not provided answers to these questions. The tests were coded with a number to allow for comparison between pre- and posttest scores, as well as location of rotation and shelf exam (final exam) score. The students were also given a handout with self-study cases in emergency psychiatry and told that they should work through the cases during the rotation. No intervention or reminder of the cases occurred during the rotation.

On the last day of the rotation, the students were re-tested on the critical psychiatric emergency management skills. They were also asked whether they had worked through the case handout they had been given and whether or not it had been helpful. The students’ pre- and posttest scores were compared to their location of rotation and shelf exam score. A t test for statistical significance was used to evaluate this data and to look for significant associations.

Data was collected on 81 students. About one-half of those students (N=42) indicated that they had worked through the cases. There was no apparent pattern to the students who elected to work on the cases; some students from each rotation assignment location completed the self-study cases. The proportion of students who completed the cases is consistent with other medical student self-study activities in other areas as some students either choose not to complete or forget assignments that they are given. All of the students who used the cases reported that they were helpful. All of the students performed approximately the same on the pretest, but there was a significant difference in their posttest scores depending on whether they had used the cases. The mean of the pretest scores was 47 (for each group), while the mean of the posttest scores of those who did not use the cases was 58 and the mean of the posttest scores of those who did use the cases was 71 (p<0.01). There was no association between where the students did their rotation and whether they completed the cases. There was also no association between the rotation location and the pre- or posttest scores; thus it appears that the opportunity to spend clinical time in psychiatric emergency services was not a predictor for learning key skills in emergency psychiatry.

There were significant limitations in this small study. Only students from 6 months of the year were tested (October through March 2000—2001), and the students made their own choices about whether to do the cases (there was no way to randomly assign the students to this task, since the self-study cases were optional). There is probably some selection bias involved in the posttest scores in that students who were either harder working in general or were more interested in psychiatry might have been more likely to complete the cases. However, since one-half the students elected to do the self-study questions and a much smaller number than that chose to go into psychiatry, it is unlikely that interest in the field is the sole explanation for the difference in scores. In addition, the fact that the harder-working students might have chosen to do the tests does not necessarily invalidate the results as presumably students who emulate the actions of the harder-working students would do better.

Another limitation in this study is that the pre- and posttest scores on the critical skills assessment did not have any significant relationship to the students’ scores on the psychiatry shelf exam, although the students who used the cases clearly improved in skills critical to psychiatric emergency management. There was an association between where the students did their rotation and their shelf scores: students at one offsite hospital did significantly better than those who rotated through the university inpatient unit. The issue of what is necessary in order to improve students’ self-exam scores is another problem that bears investigation.

Medical student clerkships in psychiatry offer an ideal, albeit brief, opportunity for students to refine their interview techniques and learn how to deal with common ailments (such as depression and substance abuse) with which they will need to be familiar, regardless of their future specialty (3). Further, these future practitioners need the skills to appropriately assess risk for suicide, as they will be on the front lines seeing patients at risk (4—6). In addition, the third-year medical student clerkship in psychiatry provides an important place and time to recruit future residents in the field (7). Any measure that could improve students’ skills or increase their enthusiasm for the specialty would be useful to academic psychiatry (8).

The use of independent study in case scenarios is a potentially useful and fun way for students to learn about important issues in emergency psychiatry that they might not have access to because of the variability of their clinical experience in the clerkship. Although the significance of psychiatric emergency cases on the overall performance of a cohort of students at the University of Michigan Medical School is not clear, it is apparent that students’ knowledge about management of critical issues in psychiatric emergencies was significantly improved by these self-study cases. It is worthwhile to explore the ways in which self-study cases could further add to the psychiatry clerkship. The availability of cases that discuss common clinical problems can overcome inevitable unevenness in clerkships. Further, students’ interaction with case-based material can provide an additional mechanism by which to constructively evaluate student performance, particularly through assessment in patient simulation settings (9).

The case material that was used to augment student exposure to emergency psychiatry is currently under development to transform the cases into interactive computer activities. Each question in the interactive computer sequence will represent a branch point for the students (who might accidentally allow their computer patient to commit suicide, for example, if they chose to make the wrong intervention). In addition, these cases could be used for education outside of psychiatry. The patients and problems confronted by emergency psychiatrists are not only seen in emergency psychiatric facilities, but also (or even more frequently) in general emergency departments. Case based emergency psychiatry teaching (especially in computer applications) could help improve emergency physician training in psychiatry (10).

The authors gratefully acknowledge Matthew A. Gillery for his research assistance and Karen Milner, M.D. for her technical advice.