Academic Psychiatry 29:47-51, March 2005
© 2005 Academic Psychiatry
The "Shrinking" Clerkship: Characteristics and Length of Clerkships in Psychiatry Undergraduate Education
Renate H. Rosenthal, Ph.D.,
Ruth E. Levine, M.D.,
David L. Carlson, M.D.,
Kathleen A. Clegg, M.D. and
Ross D. Crosby, Ph.D.
Dr. Rosenthal is with the University of Tennessee Health Science Center, Memphis, Tennessee; Dr. Levine is with the University of Texas Medical Branch, Galveston, Texas; Dr. Carlson is with the University of North Dakota School of Medicine, Fargo, North Dakota; Dr. Crosby is with the Neuropsychiatric Research Institute, Fargo, North Dakota; and Dr. Clegg is with Case Western Reserve University School of Medicine, Cleveland, Ohio. Address correspondence to Dr. Rosenthal, Department of Psychiatry, University of Tennessee Health Science Center, 135 North Pauline, 6th Floor, Memphis, TN 38105; rrosenthal{at}utmem.edu (E-mail).
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ABSTRACT
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OBJECTIVE: The authors explored the time that is currently devoted to psychiatry clerkships to determine whether "shortened" clerkships differ in course director satisfaction and evaluation strategies. METHOD: An 18-item questionnaire was sent to 150 U.S. and Canadian clerkship directors. RESULTS: The return rate was 74% (111 questionnaires). Clerkship length ranged from 4 to 8 weeks, with 6 weeks being most common (49.5% of clerkships). Only 18.9% had clerkships lasting 8 full weeks. Shorter clerkships were more likely to rely on the NBME subject test, and less likely to rely on Objective Standardized Clinical Examinations (OSCEs) or oral examinations. Most clerkship directors (81.9%) felt their evaluation procedures reflected their clerkship objectives. Among those who did not or were not sure, a majority (77.7%) felt having too few weeks was among the causes, except for 8-week clerkship directors, who did not mention clerkship length as an issue. CONCLUSIONS: The number of clerkships having 2 full months devoted to psychiatry has decreased in recent years. Shorter clerkships rely heavily on the National Board of Medical Examiners (NBME) Subject Examination as an evaluation tool, testing for book knowledge rather than clinical skills.
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INTRODUCTION
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Psychiatric education is a crucial part of the overall training of physicians. In 1999, the World Psychiatric Association and the World Federation for Medical Education emphasized the importance of psychiatric education in light of "the frequency of psychiatric problems in the general practice of medicine, the substantial factual basis of the subject, and the need to teach communication skills" (1). The authors’ recommendation for optimal clerkship length was 8 weeks, although they conceded that 4 weeks would suffice, as long as there are structured opportunities to teach psychiatry collaboratively in other clinical clerkships and in the basic science curriculum. While the mean duration of psychiatry clerkships has not changed drastically between 1988 and 2000, with the "average" clerkship lasting between 6 and 7 weeks, the number of full 8-week clerkships has progressively declined. In 1985–1986, full 8-week clerkships were found in 34% of the 135 medical schools (2). By the 1994–1995 academic year, the number of 8-week clerkships had dropped to 24% (3). In the year 2000, the "average" psychiatry clerkship lasted 6.8 weeks (4).
Currently, the structure and length of psychiatry core clerkships differ widely among medical schools. A number of clerkships are 8 weeks in length, some only 6, and some are as short as 4 weeks. Some clerkships have been combined with other disciplines such as neurology, internal medicine, pediatrics, or family practice, while others have been split between the third and fourth years of medical school. Little has been known how clerkship directors perceive these changes or how students have been evaluated in these various clerkship formats.
There is an ongoing struggle to find objective, fair, and relevant ways to test students’ attitudes, knowledge, and skills. The National Board of Medical Examiners (NBME) subject test in psychiatry has become an increasingly popular tool among clerkship directors for measuring knowledge, although it is generally not considered a good measure of skills or professionalism (5). Objective Standardized Clinical Examinations (OSCEs) are excellent tests for evaluating clinical skills and even professional behavior, though these tend to be costly and faculty intensive. Many programs cannot afford the money or time necessary to develop and administer these tests, despite their utility. In order to determine the prevailing modes of assessment, we surveyed psychiatry clerkship directors on the nature and usage of their assessments and their views on whether these procedures adequately measured their objectives. Our hypotheses were that, with the decline in the number of weeks available to teach psychiatry, clerkship directors would be less satisfied that their assessment tools measured their objectives, and the shorter duration would be seen as an obstacle. We also hypothesized that the nature of assessment and remediation might differ according to clerkship length and whether the clerkship was free standing or combined with another clerkship. This was intended as a preliminary study. The authors made a conscious decision to keep the survey rather short, hoping for a good response rate.
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METHOD
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Psychiatry clerkship directors of all accredited U.S. (N=125) and Canadian (N=16) allopathic medical schools were mailed an 18-item questionnaire, surveying evaluation and remediation practices. They were asked to respond anonymously, using a self-addressed, stamped envelope. A total of 150 questionnaires were mailed to 141 schools. Some schools with more than one clerkship site received two surveys. The initial survey was sent in November 2001, with a second mailing in February 2002. This was followed by pleas on the Association of Directors of Medical Student Education (ADMSEP) list-serv and by e-mail and telephone reminders. Clerkship directors were asked to answer questions about their evaluation and remediation procedures (in-house exam, Subject Exam, OSCEs, oral exams), clerkship structure (4 weeks, 6 weeks, 8 weeks, combined or free-standing, split rotations) and whether they believed that their clerkship assessment procedure measured their objectives. Descriptive statistics were compiled on all responses. The relationship between clerkship length and other survey responses was assessed using chi-square analyses.
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RESULTS
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Of the 150 questionnaires, 111 (74%) were returned. The reported length of clerkships is shown in Table 1.
In 2003, approximately one-half (49.5%) of psychiatry clerkships in this survey were 6 weeks in length, while 4-week (19.8%) and 8-week (18.9%) clerkships were much less frequently reported. Five-week, 7-week, and "other" categories of reported clerkship lengths were less than 3.6% each. (Clerkship directors who endorsed the "other" category included four clerkships at three weeks, four at five weeks, and four of unspecified length.) The question "Do you feel your system of evaluation reflects the learning objectives of your clerkship?" was taken to be a measure of satisfaction with the process, and it was answered by 105 clerkship directors. These findings are summarized in Table 2.
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TABLE 2. "Do You Feel Your System of Evaluation Reflects the Learning Objectives of the Clerkship?" (Course Director Satisfaction)a
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The majority (81.9%) believed that their evaluation procedures adequately reflected their learning objectives, while 18.1% were not sure or felt they did not. In the shortest (4-week) clerkships and those of "other" duration, 100% of those who doubted that their evaluation procedures adequately reflected their objectives cited "too few weeks" as one of the obstacles. For the same question, that percentage fell to 66.7% in the six-week group. In the 8-week group, 21% stated they were not sure their evaluations reflected their objectives, but clerkship length was not cited as one of the reasons. Table 3 represents the various evaluation methods, as practiced in clerkships of different lengths.
The most frequent evaluation methods were clinical evaluation (86.4%), NBME exam (65.5%), and departmental exam (37.3%). The only statistically significant difference in evaluation methods between clerkships of different lengths was the use of the oral exams. Only 4.5% of 4-week clerkships reported using oral exams for grading purposes, compared to 23.6% of 6-week clerkships, 33.3% of the "other" group, and 42.9% of eight-week clerkships. The 4-week clerkships used the NBME Subject Exam most heavily (72.7%), followed by the 6-week clerkships (65.5%) and the 8-week clerkships (57.1%). OSCEs were used by 20% of the 6-week clerkships. The 4- and 8-week programs used OSCEs with the same frequency (13.6% and 14.3%, respectively).
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DISCUSSION
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While the mean duration of psychiatry clerkships has not changed significantly, the "norm" of an 8-week freestanding clerkship is no longer a reality. In our sample only 18.9% of clerkship directors reported having a full 8 weeks. Even among these programs, 24% stated they had to share some of their time with other disciplines, and only 15% of all clerkship directors reported having an entire 2 months devoted exclusively to psychiatry. Yet, only a relatively small number actually voiced concern that clerkship length was a major problem. This percentage might have been higher if the question had been asked directly, and not embedded in a question of whether evaluation strategies reflected clerkship objectives. More research is needed into what makes for high and low course director satisfaction. Faculty are busy with patient care and administrative concerns and have learned to be flexible and "roll with the punches," but this may not translate into being satisfied with the status quo of psychiatry education. Also, perceived training deficiencies in relation to clerkship length need to be investigated further. Since student performance on the NBME Subject Exam seems unaffected by clerkship length (6); one might surmise that students in short rotations receive more focused instruction and spend more time memorizing facts. Many clerkship directors are concerned that their evaluation procedures do not really measure their true objectives. Clerkship duration is cited more often as a problem in this regard in the 4-week group. Oral exams, a good test of clinical knowledge and reasoning, are uncommon in four-week clerkships. Most clerkships deal with severe mental illness, while the shelf exam covers a broader content. Therefore, much of what the students study for their exams is based on book learning and multiple-choice recognition, rather than clinical experience. The tendency for the shortened clerkships to rely more on assessments of knowledge (e.g., the NBME shelf test) and less on assessments of skills and professionalism (OSCEs and oral exams) is also potentially problematic. High scores on Subject Exams and Step 2 of the Boards can result in a false sense of "successful" psychiatry training, shared by clerkship directors, chairmen, deans, and curriculum committees alike. The apparent trend toward a time reduction and combined experiences in the core clerkship short-changes students’ education, unless psychiatry is well integrated in the rest of the curriculum from the beginning, for example, in case-based teaching and in psychopharmacology instruction in the pre-clinical years. Psychopathology is highly prevalent in the general medical population, and it is often not recognized, diagnosed, or properly treated. Nowadays, most psychiatric problems are treated by primary care physicians. Psychiatric interventions in primary care tend to be limited to medication management, which may not always be the treatment of choice, or the only plausible treatment. There needs to be a strong focus on the comprehensive biopsychosocial treatment of patients throughout medical school, and psychiatry educators must take the lead. Medical school is the place to instill an awareness of the complexity of human behavior, to expose students to the art of medicine, and to give them the tools they can use. Laymen’s opinions notwithstanding, empathic listening and communication skills are not all there is to psychiatry. However, ours is the specialty most focused on instilling these skills in students, and they are best learned by observation and guided practice. This is more than can be accomplished even in a 2-month clerkship. The psychiatric educator can contribute a vast body of knowledge and skill by evaluating and treating patients in teaching settings outside of the traditional psychiatric turf: Somatization, mood and anxiety disorders, depression, personality issues, delirium, dementia, dual diagnosis, substance abuse, and behavioral problems are relevant to, and prevalent in all aspects of medicine. Psychiatry instruction should not be limited to a psychiatry clerkship. Students who only have a truncated exposure to the practice of psychiatry, in short clerkships with patients with serious mental illness, may never appreciate the prevalence of psychiatric problems or learn appropriate evidence-based psychiatric interventions. If the "shrinking clerkship" truly reflects diminishing student exposure to psychiatry, psychiatric educators need to take the lead and find creative ways to connect with other disciplines throughout the curriculum to maintain and prove their legitimacy as a "core" component of medical education. The students would welcome such an approach, and ultimately, the patients will benefit.
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ACKNOWLEDGMENTS
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Data contained in this article were presented at the Annual Meeting of the Association of Directors of Medical Student Education in Psychiatry, Jackson Hole, Wyoming, June 12–14, 2003.
Approval for research was granted by the Institutional Review Board of the University of Texas Medical Branch, Galveston, Texas. There are no conflicts of interest.
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REFERENCES
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- Walton H, Gelder M: Core curriculum in psychiatry for medical students. Medical Education 1999: 33(3): 204–211
- Association of American Medical Colleges: Curriculum Directory. Washington, DC, AAMC, 1985–1986
- Sierles FS, Magrane D: Psychiatry clerkship directors: who they are, what they do, and what they think. Psychiatr Q 1996; 67:153–162[CrossRef][Medline]
- Association of American Medical Colleges: Curriculum Directory. Washington, DC, AAMC, 2000, p 9
- Levine RE, Carlson DL, Rosenthal RH, et al: Usage of the National Board of Medical Examiners Subject Test in Psychiatry by U.S. and Canadian clerkships. (in press)
- Case SM, Ripkey DR, Swanson DB: The effects of psychiatry clerkship timing and length on measure of performance. Acad Med 1997; 72(suppl):S34-S36
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ABSTRACT
INTRODUCTION
