It is highly unusual for any medical school to provide uniform clinical experiences. Almost all clerkships emphasize learning by encountering patients on the wards and in the clinics. The number of patients that students encounter can vary tremendously. In one study, if the student rotated with a private inpatient attending, he or she saw a mean of 1.25 patients and had 1.08 patient write-ups during the clerkship (1). The same study found that when assigned to the emergency room, however, the student saw a mean of 41.50 patients and had 43.80 patient write-ups. Furthermore, not only the patient load but the contact hours with the resident and attending psychiatrist varied. That study noted a mean difference of five times more contact with residents and attendings in the consultation-liaison setting (20.49 hours) than in private inpatient services (4.07 hours) (1).
Not all of the variability is site-specific. Another factor is student-related. Some students are very active and will seek out clinical experiences. Others are fairly passive and can pass a clerkship without pursuing many clinical encounters (2). Consequently, the clinical experience is often opportunistic, largely unstructured and lacking predetermined objectives (3).
Portfolios or logbooks have been used for at least several decades as an attempt to provide greater monitoring of the students’ clinical experiences (4, 5). Ideally, a logbook should provide interaction between the tutor and student, continual assessment, and a feedback loop when evaluating learning activities (6). Unfortunately, logbooks often suffer from underreporting by students (7) and/or the lack of any readjustment of clinical activities based on logbook results (8).
Another worry for undergraduate medical educators is managed care and the potential for it to reduce student encounters with patients. With emphasis placed so heavily on finances, physician time dedicated to teaching is squeezed; they must see more patients in less time and morale has declined (9, 10), and time available for teaching has eroded. Morale declined because of an increasing volume of sick patients coupled with more time occupied by more extensive documentation and third-party contacts. Brodkey et al. surveyed over 800 clerkship directors in six medical specialties, and 500 directors responded. Nearly half (48%) of clerkship directors believed that faculty participation in teaching medical students decreased because of managed care, while 54% concluded faculty availability for educational administration decreased for the same reason. Furthermore, Brodkey’s group found that the perception of the negative impact of managed care was strongest in psychiatry (10). Ludmerer (11) concluded that financial pressures have “wreaked havoc on the learning environment of academic health centers.”
The varying factors influencing student-patient encounters prompted action by the Liaison Committee on Medical Education (LCME). The LCME specified that to meet ED-2 standards, clerkships must: identify the number and types of patients to be encountered, specify the degree of student involvement, monitor and verify that these encounters occur, and adjust the clerkship for each student to ensure that all students have the desired clinical experience (Appendix 1).
During the 2003–2004 academic year, only six out of 18 (33%) programs surveyed met full compliance with ED-2 standards (12). In preparation for a January 2007 LCME site visit, the psychiatry department at one medical school devoted a major part of the annual educational retreat to satisfying the new standard. Although the psychiatry department had used logbooks for several years, the logbooks did not have any validity checks and were not used to make mid-course assignment changes. Therefore, the logbook process was inadequate to meet the ED-2 standard.
In March 2005, the psychiatry department held its annual educational retreat. The retreat was well attended with nine of 16 residents (56%) and 22 of 24 faculty (92%) participating. Both off-campus sites were represented. Also included was an adjunct faculty member who supervises the substance use consultations, as well as the associate dean of education and curriculum (a psychiatrist), showing that this topic is clearly on the minds of medical educators. The major goal of the retreat was to address the ED-2 standard and to determine the types and quantity of patients that must be seen during the psychiatry clerkship.
Prior to the retreat, the clerkship director and psychiatry nurse educator reviewed the clerkship’s goals and objectives. These course objectives had been developed from a series of annual retreats (2002–2004) that used as a starting point objectives for psychiatry clerkships by Brodkey et al. (13). After reviewing these objectives, exposure to nine categories of symptoms was felt to be the core experiences that students should obtain during the clerkship.
The retreat began with an introduction of the new educational standard by the associate dean of education and curriculum. The faculty divided into three predetermined small groups (based on expertise or interest) with the charge to discuss and develop the detailed criteria needed to demonstrate completion of the clerkship objectives, including the appropriate number of patients to be seen during the 6-week psychiatry clerkship. After each group reached a proposal, the faculty reviewed the group recommendations and agreed on the final criteria for each experience.
After the retreat, the consensus recommendations were summarized by the clerkship staff. The next challenge was to develop a tracking system to comply with the ED-2 standard. The goals for the system were simplicity, ease of use, and convenience for faculty signoff. This led to the development of the Required Patient Encounter (RPE) card. The card is designed to fit inside a pocket Diagnostic and Statistical Manual which is carried by the students at all times. The front side of the card details the types and quantities of patients that each student must see to satisfactorily complete the clerkship (Figure 1, side 1). The back side has a separate row for each required patient encounter (Figure 1, side 2). Students must date the encounter, circle the setting and level of participation, and then solicit a faculty or resident signature for verification purposes. Students are required to obtain the faculty or resident signature at the time of the encounter.
A corollary requirement of the ED-2 standard is, “Courses and clerkships will monitor and verify, by appropriate means, the number and variety of patient encounters in which students participate, so that adjustments can be made to ensure that all students have the desired clinical experiences” (2). We believe the card system will help facilitate meeting the ED-2 corollary requirement. A mid-clerkship evaluation of the RPE card identifies any deficits in case material. If deficits are found, a corrective plan can be established.
If there are significant deficits found at the mid-term evaluation, student assignments can be changed. Deficits found during the fourth or fifth week can be corrected by finding appropriate patients in the inpatient and/or outpatient settings. Deficits that exist by the last week of the clerkship are handled through development of interactive back-up cases for each category. These cases include paper cases that the student discusses with a clinician (not just given to the student to read). Alternatively, pre-trained, standardized patients can be used.
Data were collected on how the students met the encounters (i.e., interview, partial interview, or observation), anonymous student and faculty evaluation of the process, and correlation between outcome measure (e.g., Shelf exams and end-of-clerkship clinical examinations and percent completion of the encounters).
During the first three rotations, three of 25 (12%) students required corrective action during the rotation. One off-site student was moved to the main campus because of insufficient clinical experience. Another came to the main campus to complete an encounter with a geriatric patient and a third student needed an interactive case presentation on attention deficit hyperactivity disorder (ADHD) symptoms to meet the requirement.
Ninety-two percent (23 of 25) of the students in the first three rotations of academic year 2005–2006 completed the evaluation questionnaire. Using a Likert scale, both faculty and students found the system easy to use (Tables 1 and 2). One faculty member noted, “I thought it was a great way to keep track of patients they have seen.” One student commented that the RPE card system was “a good tool to keep track of required patients. Very easy to use.”
On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), the students were more neutral (3.6) as to whether the card promoted an equality of experience, though the score was similar to that of faculty perception (3.7). Although one faculty member indicated that “The card helps ensure that students seek a variety of experiences/patients,” another faculty member wrote, “The card is for administrative purposes. Let us avoid confusing this with actual quality.”
Nevertheless, students did seem to profit more than merely fulfilling an academic requirement. Students’ comments included, “I think the cards were well-utilized and an easy way to … see the main bread and butter of the psychiatry field.” The student went on to write, “The cards ensured not only that we saw these patients, but also that we KNEW [student’s emphasis] we saw them. I had to ask a resident about maladaptive behavior, seeking a patient to fill the requirement. It went into a teaching point where she instructed me on what maladaptive behavior consisted of and was able to point out examples in several patients I had seen or [who] were currently on my service.”
The enduring pattern of maladaptive behavior and/or inner experience was also confusing to another student who commented that requirement was “difficult to fulfill.” Another student noted, “Although I completed the requirement, it was difficult in finding three anxiety patients, but that just depends on location of the clinical experience.” Two students suggested that having both logbooks and RPE cards were redundant and would have preferred to do one or the other. In contrast, two other students commented that the cards were “very convenient” and an “… overall good system. No complaints.”
As one might predict, students varied widely in meeting the requirements through interviewing, partial interviewing, or observing (upper panel, Table 3). Overall, slightly less than half of all RPEs were performed by observation (lower panel, Table 3). One student met the RPE by interviewing or partially interviewing 75% of the requirements. Conversely, two students fulfilled the RPEs by interviewing or partially interviewing 19% of the requirements. The three most common RPEs that were met by interview were: suicidal (50%), substance use (46%), and mood (38%) (Table 4). The three most common RPEs to be met through observation were: ADHD (60%), psychotic (58%), and anxiety (48%) (Table 4). Table 5 lists Pearson correlation coefficients for the percent of each type of encounter (i.e., interview, partial interview, or observation). There was a significant inverse relationship between Shelf examination score and percent of encounters observed (r=−0.59, p=0.0019).
By establishing the types of psychiatric symptoms that students must see during their 6-week clerkship, the RPE system addresses two historic sources of variability of clerkship experience: site-specific and student-specific. Each student must document the following with faculty or resident verification: interviewing, partially interviewing or observing 16 types of symptoms.
Faculty acceptance of the RPE system was aided by involvement of 92% of the faculty and 56% of the residents in an afternoon retreat to develop the RPE system. Consequently, faculty acceptance made it easier for students to use the RPE card and to complete the requirements. A potential limitation with the current RPE system, however, is that the system does not specify how many of the systems must be “interviewed” versus “observed.” At present, only substance use requires that at least one of the student’s interviews be entirely observed by faculty or students. Theoretically, a passive medical student could interview only one patient (with substance use issues). The first three rotations indicate a significant inverse correlation exists between the percentage of encounters met through observation and scores of the end-of-clerkship Shelf exam.
Future directions include the further analysis of data on “interview,” “partial interview,” and “observe.” Data from the initial five clerkships will be presented at the next annual educational retreat of the psychiatry department. Attendees will be charged with analyzing the data from the first 6 months of the new system and determining if the percentages of “observed” versus “interview” should have a maximum set for meeting requirements through observation.
A second question for a future retreat is whether the intellectual disability category will need to be redefined and if delirium will need to be made a separate mandatory category. One of the graduation requirements from Southern Illinois University’s School of Medicine is for the student to see an individual with impaired consciousness. While this requirement certainly can be met during their medical or surgery rotations, the psychiatry faculty will need to determine whether seeing someone with impaired consciousness should be required for all students during the clerkship.
What started as an exercise to meet the ED-2 standard has expanded into an opportunity to more critically analyze what the faculty believes all students should encounter during the psychiatry rotation.