Recruitment into the psychiatric profession was at an historical low between 1980–1986 and 1991–1997 (1–3), and, generally, medical students expressed a lack of enthusiasm for psychiatry (4). Recently, however, psychiatry has become a more popular career choice among students from U.S. medical schools. In one study, medical students’ attitudes at the end of their junior psychiatry clerkship have been shown to be the strongest predictor of eventual specialization in psychiatry (5).
A number of studies have examined medical students’ attitudes toward psychiatry and the clerkship experience. Positive factors affecting medical students’ attitudes have included their interest in human behavior, personal aptitude, and the perceived quality of patient care (6). During the 1950s and 1960s, when recruitment was at its highest, most students were primarily observers in state hospital inpatient units. However, exposure of medical students to severe, chronic psychiatric illnesses did not seem to affect students’ attitudes toward psychiatry (7). Researchers have generally concluded that medical students’ attitudes and views of psychiatry were mostly positive (8), despite relatively few students entering the profession.
Existing literature also suggests that the quality of the psychiatry clerkship during medical school may be the single most important modifiable influence on recruitment into psychiatry (9–12). However, psychiatry clerkships between U.S. medical schools vary considerably with respect to setting, content, expectations, and duration—making the definition and assessment of clerkship quality difficult. For example, studies examining the influence of location and setting of clerkship on medical students’ attitudes have yielded mixed results (13, 14). Compared to traditional teaching methods, new variations in duration of clerkship and teaching strategies have been as effective at changing medical students’ attitudes toward psychiatry (15).
Relatively few studies have addressed medical students’ attitudes, the clerkship experience, and its relationship to standardized measures of performance. Students at alternative or innovative sites have performed comparably on examinations and rated teaching equivalently compared to standard clinical sites (16). Researchers have found that scores for medical students who take the United States Medical Licensing Examination (USMLE) subject exams during clerkships do not tend to increase as the year progresses; however, their USMLE Step 2 scores are higher the closer to the Step 2 exam the students take the clerkship (17).
This survey was undertaken in an attempt to understand more about the attitudes of medical students toward and the quality of the junior psychiatric clerkship experience at Ohio State University. Medical students’ attitudes toward the various curriculum components and modes of learning were assessed. It was hypothesized that students’ attitudes toward psychiatry would improve upon completion of the psychiatric clerkship; that students with more positive attitudes before and/or after clerkship would perform well on standardized multiple choice examinations; and that students would have definite preferences about the components of the clerkship that they perceived to be most helpful.
From July 2002 to June 2003, a total of 184 third-year medical students participated in the junior psychiatric clerkship based at Ohio State University. The rotation is comprised of a 4-week clerkship that is completed sequentially with neurology in 8-week blocks: July/August, September/October, November/December, January/February, March/April, May/June. Students rank preferences about the timing and sequence of core clerkship rotations. The college assigns student preferences into six rotation blocks. For instance, students requesting psychiatry early are randomly assigned to complete this rotation within the first three blocks (first half) of the academic year. Students requesting to take psychiatry later, often those more interested in a psychiatric career, are randomly assigned to one of the three later rotation blocks.
All students identified their preferred inpatient and outpatient clinical sites for psychiatry. Students spent one-half day each week in the outpatient clinic and the remainder of their time was spent on an adult inpatient, child inpatient, or consultation-liaison service. All students were required to view electroconvulsive therapy (ECT) and to take evening call on a rotational basis in the hospital emergency room. The clinical experiences of individuals varied considerably by site, whereas all didactic presentations and tests were administered collectively. All preceptors were department of psychiatry faculty members or clinical faculty from the community. Psychiatric residents at varying levels of training worked closely with medical students throughout the rotation.
At the conclusion of the clerkship, students take an examination that was developed and standardized internally within the department, as opposed to the National Board of Medical Examiners Psychiatry Subject Examination. There are multiple versions of the departmental examination drawn from a large bank of validated test questions. The students’ results on the departmental examination have been shown to have a high correlation with performance on the psychiatry section of USMLE Step 2 (18).
Administrative support staff distributed, collected, and coded the surveys to ensure confidentiality of the subjects to the author. The college requires students to complete evaluations of rotations and faculty supervisors, and this survey was considered exempt by Ohio State University Behavioral Institutional Review Board (IRB). The intent of the surveys was to evaluate the attitudes of students toward existing educational tools and facilitate curriculum development. The surveys were utilized to establish baseline parameters of attitudes toward the existing curriculum and the platform upon which IRB approval for future projects would be pursued.
During orientation, students completed a survey asking them to rate their attitudes toward the psychiatry clerkship and the discipline of psychiatry and their interest level in choosing a psychiatric career. Students were asked to rate factors that have influenced their attitudes. Factors inquired about included the following: exposure to psychiatry during earlier years of medical school; interactions with medical students, residents and attending physicians; and other psychiatric experiences. Depending upon the question, attitudes were rated on a 5-point Likert-type scale, with possible choices including strongly negative, negative, neutral, positive, and strongly positive, or on a 1–10 scale, with 10 indicating the highest (most favorable) and one indicating the lowest (least favorable) scores possible.
At the end of the rotation, students completed the postclerkship survey that assessed their satisfaction with the clerkship; their interest in choosing a psychiatric career; and their attitudes toward the clerkship and specialty. Students also ranked numerically and in a Likert-scale manner their perceptions of helpfulness of various curriculum components, such as faculty teaching, resident teaching, conferences, lectures, text material, outpatient experiences and inpatient experiences. Additionally, students were asked to identify, on a scale of 1–10, the psychiatric conditions they felt the clerkship prepared them most to recognize and treat. Mood disorders, psychotic disorders, substance-related disorders, anxiety disorders, cognitive disorders, personality disorders, somatoform disorders, eating disorders, and chronic pain issues were included for this ranking. These disorders were teaching priorities of the department, considered essential to all students, regardless of ultimate career specialty. Finally, timing of clerkship and results on the standardized multiple-choice examination were recorded for each student.
Pre- and postclerkship data and test performance for each student were entered into a computer database. Data from fourth-year students who were completing the psychiatric rotation at a nontraditional time in medical school training were not included in the analysis. Data were assessed using analysis of variance (ANOVA) regression with Pearson correlations where indicated. Timing of clerkship was coded using 1=July/Aug, 2=September-October, etc.
Medical students responded that the most influential aspects of their preclerkship attitudes toward psychiatry were their interactions with faculty physicians prior to their clerkship (56%); other medical students (17%); resident physicians and first/second year of medical school behavioral science curriculum (13% each); and other nonspecific experiences (1%). The results of surveys assessing students’ pre- and postclerkship attitudes toward psychiatry are listed in Table 1.
Ninety-four percent of medical students responded with preclerkship attitudes toward the psychiatry clerkship that were strongly positive, positive or neutral, while 92% maintained these attitudes on the postclerkship survey. Six percent of students indicated that they had negative or strongly negative preclerkship attitudes, with an additional 2% reporting these attitudes at the conclusion of the clerkship. However, the clerkship experience influenced those students with initial neutral views, as they developed predominantly positive attitudes at the end of the rotation.
Ten percent of students (N=18) responded as “highly interested” when asked of their preclerkship interest level in choosing a career in psychiatry, while 11% (N=20) responded with high interest in choosing a psychiatric career at the conclusion of the rotation. Although the overwhelming majority responded with positive or strongly positive views of psychiatry and satisfaction with the clerkship, many students (N=49) responded that the clerkship experience influenced their decision not to choose a career in psychiatry.
Students were asked to rate their satisfaction with the psychiatry clerkship, compared to other required third-year clerkships and their overall psychiatry clerkship experience. Regression analysis compared medical students’ performance on the standardized multiple-choice examination to students’ overall satisfaction with the psychiatry clerkship and pre- and postclerkship attitudes toward the discipline of psychiatry and the psychiatry clerkship. Students’ overall postclerkship satisfaction rating was significant and highly correlated with examination performance, accounting for 50% of variance. Their pre- and postclerkship attitudes toward the psychiatry clerkship and discipline also strongly correlated with examination performance. Analysis of examination performance and pre-and postclerkship attitudes are shown in Table 2.
As part of the postclerkship evaluation, students were asked to rate on a scale of 1–10 (10=most favorable ranking) the components of the clerkship that they felt were most helpful with increasing their psychiatric knowledge. Table 3 illustrates these results.
Students’ overwhelmingly ranked inpatient and outpatient experiences followed by clinical resident and faculty teaching, and then instructional materials as elements most helpful to them. Case conferences, which consisted of discussions with no patient present, were rated very low by students. The seven various clerkship teaching components and the timing of clerkship (months) were compared to clerkship standardized test scores using ANOVA. The only statistically significant variable positively affecting test performance was months of clerkship rotation (beta [standardized regression coefficient]=0.146, p<0.03). That is, those students who took the clerkship later in the year achieved a higher measure of standardized test performance, and students’ perceived helpfulness of the clerkship teaching components did not significantly impact performance.
The postclerkship evaluation also asked medical students to rank the conditions covered in the rotation that they felt most confident to diagnose and treat. Students ranked each on a 1–10 point scale (10=most confident; 1=least confident) and in ordinal manner. Table 4 illustrates these results.
Compared to previous studies, this survey reveals that a majority of students had favorable attitudes toward the psychiatry clerkship and discipline prior to experiencing the clerkship. Positive attitudes and high satisfaction remained at the conclusion of the clerkship among the majority of medical students. The clerkship experience appeared to be most influential for the subgroup of students with initially neutral attitudes toward psychiatry, affirming that the clerkship is a modifiable influence on student attitudes. It is of interest, however, that medical students expressed that the rotation significantly influenced their decisions not to choose a psychiatric career. As in previous studies, students with initial positive attitudes toward psychiatry were those indicating a strong interest in becoming psychiatrists.
Although the data revealed that approximately 10%–11% of medical students expressed high interest in choosing psychiatric careers, in recent years about 3%–5% of medical students from Ohio State University entered psychiatry based on resident matching program data. This raises the question of how to engage potentially interested students before the residency selection process in their fourth year of medical school. Future studies could assess medical students’ attitudes and test performance as it relates to outcomes such as choice of residency or performance on national standardized tests.
Before they had completed the clerkship, students rated faculty physicians they were exposed to during the first 2 years of medical school or during third-year nonpsychiatric rotations as influential in their opinions about psychiatry. “Faculty physicians” refers to nonpsychiatrists, as students receive fewer than 15 contact hours with psychiatrists during the first and second years of medical school. Perhaps surprisingly, students did not generally reveal that “other” factors—such as personal, familial, or patient-care-related experiences influenced their attitudes. Following the clerkship, students had positive perceptions about inpatient and outpatient experiences, yet their lower perceptions about the helpfulness of faculty teaching and other curriculum components were not anticipated.
It is not surprising that students who expressed high satisfaction with the clerkship performed well on the standardized clerkship examination. As in previous studies, this study reaffirms that timing (month) of clerkship may be predictive of test performance. Additionally, students appeared to have positive attitudes at the conclusion of the clerkship, regardless of test performance. Since the majority of students who fail the examination do so early in the academic year, it poses the question of whether curriculum adaptations can be implemented to reduce this trend.
At the conclusion of the clerkship, students expressed definitive attitudes toward the various curriculum components and confidence in their abilities to diagnose and treat psychiatric conditions. Students readily identified mood, psychotic, and cognitive disorders as their areas of strength, and it is not coincidental that these are the same conditions they would most likely be exposed to during their core inpatient psychiatric rotation. Students consistently request more exposure to the management of child & adolescent conditions and personality disorders, perhaps attaching relevance of these conditions to everyday practice, regardless of specialty. Much of the feedback the students provided about the clerkship curriculum is now being used to strengthen areas of clinical teaching and adapt other modes of learning as necessary.
Although much of the data support findings from research at other academic sites, these results may not be generalizable given the considerable variability of the psychiatric clerkship experience between medical schools. The results of this study identify the experience of only one medical school in the Midwest. Another limitation is that while every attempt was made to assign students to preferred rotation timing and clinical sites, not all students invariably received their first preferences. Medical students’ rotational timing of clerkship, especially, could influence attitudes and test performance and limit the results of this study.
Despite instructions otherwise, students may perceive that negative answers on the surveys, particularly preclerkship attitudes or discussing “other” influences on perceptions of psychiatry, could result in bias, such as less favorable treatment during the clerkship or less favorable outcomes on their clinical evaluations or overall clerkship grade. Students have experience completing confidential evaluations in their first and second years, and their prior third-year clerkships. The lack of anonymity could inflate positive responses. Finally, a larger sample size or data collected sequentially over years may be more revealing, especially as it relates to students’ ultimate decision to enter the psychiatric profession.
Despite these limitations, the results add to the existing literature about the pre- and postclerkship attitudes of medical students toward psychiatry and reaffirm that timing of rotation is a critical factor in standardized test performance. The study has other implications for medical student education. For instance, the clerkship can positively influence and reinforce their perceptions of psychiatry, ultimately improving their attention to psychosocial aspects of patient care, regardless of specialty choice. The study also supports that there are factors before, during, and after the psychiatry clerkship that may affect students’ attitudes and their intent to pursue psychiatric residency following medical school.
The results of this survey have been used to generate baseline measures of medical student attitudes about psychiatry and about the department’s existing curriculum. The next challenge, currently underway, is utilizing an IRB-approved study to demonstrate the effects of curriculum modifications on student attitudes, test performance, and recruitment patterns.