Academic Psychiatry 26:102-104, June 2002
© 2002 Academic Psychiatry
Length of Psychiatry Clerkships
Recent Changes and the Relationship to Recruitment
Michael Serby, M.D.,
James Schmeidler, Ph.D. and
Jeremy Smith, M.D.
Dr. Serby is affiliated with the Department of Psychiatry, Beth Israel Medical Center, New York, NY. Dr. Schmeider is with the Department of Psychiatry, Mount Sinai School of Medicine, New York, NY. Dr. Smith is with the Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY. Address correspondence to Dr. Serby, Department of Psychiatry, Beth Israel Medical Center, 16th Street at First Avenue, New York, NY 10003.
ABSTRACT
The authors assessed the extent of change in the length of psychiatry clerkships in U.S. medical schools from 1995-1996 to 1998-1999 and explored the relationship between clerkship length and percentage of medical students choosing psychiatry as a career. Data from 124 U.S. medical schools over 4 years included clerkship length in weeks and percentage of graduating students entering psychiatry residencies. Fifteen schools sustained reductions in rotation length; the mean clerkship measured in weeks decreased for the entire sample from 6.27 to 6.04 (t=3.086, P<0.003). There was no significant correlation between clerkship length and recruitment into psychiatry. There appears to be a trend toward shorter psychiatry clerkships in recent years; however, there is no demonstrable relationship between length of clerkship and medical student interest in psychiatry as a career.
Key Words: Clerkship Length • Recruitment
Recruitment of U.S. medical school graduates into psychiatry residencies has been a process of varying difficulty over the past few decades (1). The last half of the 1990s was a low point (2), leading to considerable analysis of factors that may play a role in medical student decisions about a career in psychiatry. Some factors in career choice include lifestyle expectations, student indebtedness and monetary rewards of specialties, liberal arts versus science background in college, denigrating attitudes toward psychiatry both within and outside medical schools, and the success of clerkships in creating interest in the field (3–8).
A variety of features of clerkships may be relevant. Active involvement of students in patient care, the type of clinical setting, the quality of supervision by faculty and residents, and the nature of the patient population may be major determinants of recruitment success (1,4,7–10). There has been limited study of the length of clerkships as a factor in medical students' choice of psychiatry. Sierles (11) used questionnaires to query directors of medical student training in psychiatry at 122 medical schools about factors determining career choice. The impression of these educators was that clerkship length was not a factor.
American medical schools vary in the degree of emphasis on psychiatry in the third year of their curriculum, most psychiatric clerkships ranging from 4 to 8 weeks long. Considering the difficulty in conveying a solid notion of psychiatric knowledge and treatment in a short period, the time allotted might be essential. This issue takes on new relevance in the face of what appears to be a national trend for medical schools to diminish the duration of psychiatry rotations in the third year (2). Could such a change hamstring our field even further, leading to greater recruitment problems?
The current study is an effort to assess the extent of changes in medical schools' psychiatric rotations and to address the question of impact of psychiatry clerkships' durations on career choice in all U.S. medical schools. The extent of change in rotations in these schools over a four-year period (1995–1999) is explored. The relationship of length of third-year clerkship in psychiatry to decisions to match to psychiatry residencies is also determined. In contrast to the study of Sierles (11), this report is based on data showing the absolute figures regarding choice, rather than the impression of the directors of medical student education.
METHODS
The following data were obtained from the American Association of Medical Colleges (AAMC) for each of the academic years 1995-96, 1996-97, 1997-98, and 1998-99: length (number of weeks) of third-year psychiatry clerkships for each U.S. medical school (n=124), and total number of graduates per school. The National Resident Matching Program (NRMP) was contacted and provided numbers of graduates (anonymity was protected) from each school matching to all psychiatry programs (general and combined) for the same four years as the AAMC data. These figures were used to calculate a percentage of graduates entering any psychiatry residency for each of the four years for every school.
The number of weeks of the clerkships for all 124 schools at the beginning of the study was compared with the number of weeks during the last year of the study. A matched-samples t-test was performed for this comparison.
The length of the clerkship was constant over the four years in 85.5% of schools. Therefore, for each school the length of the clerkship and the proportion selecting psychiatry were averaged over the four years. To explore the relationship between rotation length and recruitment, a Pearson's correlation of these averages was calculated.
RESULTS
The percentages of varying rotation sizes over the four years were as follows: 4-week rotations increased from 11.3% of the sample to 15.3%; 5-week rotations increased from 4% to 5.6%; 6-week rotations increased from 55.6% to 57.3%; 7-week rotations dropped from 5.6% to 3.2%; and 8-week rotations fell from 22.6% to 18.5%.
The length of the third-year clerkship in academic year 1995-96 differed from the length in 1998-99 at 18 medical schools. Among these schools, 15 decreased the clerkship by a mean of 2.1 weeks and 3 increased by a mean of 1.3 weeks.
The mean number of clerkship weeks in 1995-96 was 6.27, and in 1998-99 it was 6.04 (t=3.086, df=123, P<0.003).
For all 124 schools, there was no significant correlation between clerkship length and percentage of graduates matching to psychiatry residencies (r= -0.011, not significant).
DISCUSSION
Approximately one-seventh of American medical schools changed the length of their third-year psychiatry clerkship during the latter part of the 1990s, 83% of these changes representing a reduction in number of weeks by a mean of 2.1. The decrease for all U.S. medical schools was significant, even though most schools did not change. This may represent a trend that could foretell further reductions nationwide, but the small number of medical schools that changed suggests these data must be considered preliminary. Greater emphasis on primary care experiences in the curriculum may be viewed by many schools as a more appropriate use of time, given the progressive relative increase in primary care trainees and practitioners (12). Thus, larger reductions could occur in the future.
This study also demonstrates no correlation between length of clerkship and popularity of psychiatry as a potential career, as measured by students choosing general or combined psychiatry residencies. It is possible, though, that the effect of changes in rotation length may not be seen immediately and may be reflected only one year or more after such modifications. At present, no data are available to examine this prospect.
Although many studies have explored factors influencing the career choice of psychiatry, few have actually looked at the impact of rotation length. A comparison between 31 students who chose a psychiatric career and 649 who did not found no significant difference between the two groups when contrasting their chances of having had a 4-week versus a 6- to 8-week clerkship in psychiatry (8). As mentioned above, in the Sierles study (11) there was no effect of clerkship length. Duration of clerkship has also been analyzed as a factor in subsequent performance on Step 2 of the United States Medical Licensing Exam (USMLE), and no significant difference was found for students assigned to a 6-week versus an 8-week rotation; clerkships shorter than 6 weeks were not included in that study (13). In another study, an 8-week clerkship was also rated higher than a 6-week one in terms of "clinical experience," but no effect on recruitment was noted (14).
Although the clerkship has been viewed as an important attraction into the field, emphasis on quality of the experience appears to be more relevant than emphasis on quantity of training time. It may be appropriate, though, to ask whether future quality improvements would be of only limited value in recruitment if embedded in briefer clerkships. In other words, the lack of correlation described above between clerkship length and recruitment could theoretically change in an atmosphere of universally high-quality rotations. However, whether clerkships remain at their present lengths or continue to diminish, psychiatric departments should focus primarily on better rather than longer rotations.
It is not necessarily easy to determine what constitutes higher quality of experience. Teaching of medical students by faculty, particularly senior faculty, rather than by residents has been cited as one factor (1). Enriched programs such as the one at the University of Maryland (15) may also prove useful. It has also been found that medical students are more likely to choose psychiatry after outpatient rotations as opposed to other clinical assignments (7). Each of these measures may be problematic, however, in the evolving health care system. Faculty are required to spend increasing amounts of time in direct patient care. Enriched programs are difficult to structure without adequate faculty time and in a climate where primary care education is granted increasing allotments of curriculum time. Outpatient areas are generally less remunerative than inpatient settings, limiting faculty availability even further.
Perhaps an emphasis on factors that enhance recruitment is not the best way to approach medical school didactic issues in psychiatry. We should strive to effectively teach some basic principles to all students, emphasizing the universal importance of the mental status examination and the recognition of major mental disorders. The choice of psychiatry as a career may be decided upon by many students before medical school (15), although the majority of students change their specialty preference during medical school (16). The introduction to psychiatry within medical schools may serve to enhance interest if our field plays its role in developing good physicians.
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