Psychiatry Clerkship Research Articles

The Psychiatry Institute for Medical Students: A Decade of Success

Recruiting medical students into psychiatric residency programs has received much attention. In the 1980s and 1990s, North American psychiatric residency programs experienced numerous barriers to recruiting highquality medical students (1–5). This remains a problem around the world. The literature suggests that experiences during medical school, personalities of applicants, and beliefs about the practice of psychiatry are all strongly associated with the decision to enter a psychiatric residency. Recruitment strategies have been widely recommended to bolster positive psychiatry-related experiences and to alter negative perceptions (6–9). In the mid-1990s, only about 4% of U.S. and 6% of Canadian medical school graduates chose psychiatry (10, 11). More recent studies focused on perceptions and attitudes of medical students about psychiatry careers (12– 17). While initial interest is still the most influential factor, positive experiences during psychiatry clerkships and electives have been described as “modifiable programmatic factors that could enhance recruitment to psychiatry” (17). The Psychiatry Institute for Medical Students at the University of Toronto in Ontario was initiated in 1994 as a novel recruitment strategy (18). To our knowledge, similar programs have not been reported. As an indication of how much the recruitment situation has changed in Toronto, the 2008 Canadian Resident Matching Service match was successful in filling all 28 postgraduate year 1 (PGY-1) psychiatric residency positions at the University of Toronto as well as two international medical graduate positions—a total of 30 spots, up from 24 spots 2 years ago (19). As of July 2007, the University of Toronto has 138 psychiatric residents from PGY-1 to PGY-5.

Psychiatric OSCE Performance of Students With and Without a Previous Core Psychiatry Clerkship

The OSCE has been demonstrated to be a reliable and valid method by which to assess students' clinical skills. An OSCE station was used to determine whether or not students who had completed a core psychiatry clerkship demonstrated skills that were superior to those who had not taken the clerkship and which areas discriminated between clerkship completers and noncompleters. One hundred thirty-six students took a 48-item, fourth-year OSCE with one psychiatry station. Sixty-three (46%) had already completed psychiatry, and 70 (51%) had not, with three unknown. Students were to take histories, perform mental status examinations, assess dangerousness, and propose the differential diagnosis and treatment plans. Nine items differed significantly between completers and noncompleters, six concerning phenomenology and mental status and three concerning differential diagnosis. There were no differences regarding history, communication skills, or recommended interventions. Students may learn history taking, communication, and treatment planning in many settings. However, for the mental status examination, phenomenology, and differential diagnosis, completing a psychiatry clerkship was associated with better OSCE performance.

Anxiety, Dissociative, and Somatoform Disorders: Team-Based Learning Module

Abstract This is used as the didactic method for our third-year medical student's clerkship in psychiatry at the University of Texas Medical Branch School of Medicine. It was developed in 2008, and...

Nigerian Medical Students Attitudes to Unmodified Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an effective and affordable form of treatment for a range of psychiatric disorders. Historical antecedents, the media, and movies have generated myths about its continued use and relevance. We explored medical students' knowledge of and attitude to ECT on completion of an 8-week clinical rotation (clerkship) in psychiatry. A cross-sectional survey was carried out among final-year medical students at the end of a clerkship in psychiatry using a self-administered questionnaire adapted from previously published work, to assess their attitudes to and knowledge of unmodified ECT. Knowledge of medicine, psychiatry, and ECT were self-rated as average by most students. Most had an interest in pursuing psychiatry as a profession and would receive ECT if judged clinically appropriate. Most students had positive attitudes toward ECT; the vast majority thought it was a relevant form of treatment and did not think that ECT was used to control violent or used by government to torture opponents. Although an overwhelming majority did not think ECT was outmoded or causes permanent brain damage, answers about pain associated with ECT and about the dangers associated with the procedure seem to be more evenly split. A minority thought that ECT was used only in the poor and should not be given to the elderly or children. A substantial majority thought that ECT was the treatment of last resort. Respondents who were likely to choose psychiatry as a profession agreed that ECT causes pain, but disagreed that it was used by governments to torture political opponents or that it causes permanent brain damage. Students with minimal knowledge of ECT showed more negative attitudes toward the myth that ECT is misused and should be a treatment of last resort. The similarity of the attitudes of students exposed to unmodified ECT with attitudes of students exposed to modified ECT suggests that modification has made little impact on the attitudes of health professionals. The importance of lectures, patient follow-up while on clinical rotations has significant contributions in shaping attitudes and should be harnessed during training.

Student Experiences with Competency Domains During a Psychiatry Clerkship

The authors reviewed medical student encounters during 3 years of a required psychiatry clerkship that were recorded on a web-based system of six broad competency domains (similar to ACGME-recommended domains). These were used to determine diagnoses of patients seen, clinical skills practiced, and experiences in interpersonal and communications skills, professionalism, practice-based learning and improvement, and system-based practice. The authors aim to understand how students are learning and growing in these domains and to modify the clerkship in an ongoing manner. Data were collected from the Dartmouth Medical Encounter Documentation System (DMEDS) for all student encounters in required third-year psychiatry clerkships during academic years 2004-2007, in which students had intensive involvement in patient care. One hundred seventy three students reported a total of 4,676 patient encounters, averaging 27.2 encounters per student and 1.8 psychiatric diagnoses per patient. Students met "learning targets" for anxiety disorder, bipolar affective disorder, depression, personality disorder (borderline), posttraumatic stress disorder, psychosis, schizophrenia, and substance abuse (alcohol), but not for disorders more likely seen in outpatient settings. For the 10 counseling skills learning targets, students only met those for family issues. In the four "newer" competency domains, students reported struggling with issues in 0.3% to 12.6% of encounters. Students documented being challenged by professionalism issues most often and recorded examples of how these competencies played out for them during the clerkship. Use of a required web-based medical encounter reporting system for student-patient-faculty encounters during a psychiatry clerkship can be of significant value in assessing what students are seeing, doing, and learning on this required third-year experience. The results provide helpful current information to the clerkship director and data that help the director modify the clerkship on an ongoing basis to better meet students' educational needs.

The Effect of Clinical Clerkship on Students' Attitudes Toward Psychiatry in Karachi, Pakistan

Attitudes of medical students toward a specialty is strongly related to their future choice of specialty. In developing countries like Pakistan, where there is a shortage of psychiatrists, there is a need to assess the effect of exposure to psychiatry on medical students. The authors conducted a survey of fourth-year medical students at Aga Khan University in Karachi, Pakistan. Psychiatry clerkship had an overall positive attitude toward psychiatric illness, patients, and psychiatrists, but no effect on students' choice of psychiatry as a career. Psychiatry teaching needs to be made more relevant to the rest of the medical curricula. This may improve students' interest and their future choice of psychiatry as an area of specialization.

Hidden in Plain Sight: The Formal, Informal, and Hidden Curricula of a Psychiatry Clerkship

To examine perceptions of the formal, informal, and hidden curricula in psychiatry as they are observed and experienced by (1) attending physicians who have teaching responsibilities for residents and medical students, (2) residents who are taught by those same physicians and who have teaching responsibilities for medical students, and (3) medical students who are taught by attendings and residents during their psychiatry rotation. From June to November 2007, the authors conducted focus groups with attendings, residents, and students in one midwestern academic setting. The sessions were audiotaped, transcribed, and analyzed for themes surrounding the formal, informal, and hidden curricula. All three groups offered a similar belief that the knowledge, skills, and values of the formal curriculum focused on building relationships. Similarly, all three suggested that elements of the informal and hidden curricula were expressed primarily as the values arising from attendings' role modeling, as the nature and amount of time attendings spend with patients, and as attendings' advice arising from experience and intuition versus "textbook learning." Whereas students and residents offered negative values arising from the informal and hidden curricula, attendings did not, offering instead the more positive values they intended to encourage through the informal and hidden curricula. The process described here has great potential in local settings across all disciplines. Asking teachers and learners in any setting to think about how they experience the educational environment and what sense they make of all curricular efforts can provide a reality check for educators and a values check for learners as they critically reflect on the meanings of what they are learning.

Psychiatry Clerkship Students' Preparation, Reflection, and Results on the NBME Psychiatry Subject Exam

Psychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE). Clerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores. The most frequently used PSE preparation material was a "step-or-prep" book, followed by practice questions, handouts, and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile. Students exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

Medical Student Psychiatry Examination Performance at VA and Non-VA Clerkship Sites

The authors examined the effects of medical student assignment to U.S. Department of Veterans Affairs (VA) Medical Center inpatient and outpatient psychiatry clerkship sites versus other university and community sites on the performance outcome measure of National Board of Medical Examiners (NBME) subject examination scores. NBME psychiatry scores were compared for stratified random samples of 70 students each for inpatient and outpatient VA and non-VA sites, controlling for baseline clinical knowledge as reflected by second year Human Behavior course scores. No significant differences were demonstrated in NBME scores between VA and non-VA sites for either inpatient or outpatient programs. Assessed students rotating through several VA clinical sites were as well prepared for NBME subject examinations as those assigned to other sites. Additional measures of educational outcome for VA sites are recommended to assess and enhance clinical education provided by the VA and to strengthen collaboration with university-based medical student teaching programs.

Discrediting the notion “working with ‘crazies’ will make you ‘crazy’”: addressing stigma and enhancing empathy in medical student education

People with mental illness around the world continue to suffer from stigmatization and limited care. Previous studies utilizing self-report questionnaires indicate that many medical students regard clinical work with psychiatric patients as unappealing, while the professionalism literature has documented a general decline in students' capacity for empathy over the course of medical school. Through in-depth interviews, this study attempts to better understand the formation of medical students' perceptions of psychiatry and the implications of that process for a more general understanding of the impact of emotionally-laden experiences on medical students' capacity for empathy. Forty-seven fourth-year medical students who had expressed interest or performed well in psychiatry were asked a series of questions to elicit their perceptions of the field of psychiatry. Interview transcripts were systematically coded using content analysis and principles of grounded theory. Stigma, stereotypes, and stressfully intense emotional reactions seemed to adversely affect the students' expected satisfaction from and willingness to care for the mentally ill, despite enjoying psychiatry's intellectual content and the opportunity to develop in-depth relationships with patients. Teaching faculty need to directly address the stigma and stereotypes that surround mental illness and actively help medical students cope with the stress that they report experiencing during their psychiatry clerkship in order to improve the recognition and treatment of psychiatric illness by newly graduating physicians. More generally, the relationships that we identify among stress, stigmatization, and stereotyping along an empathic spectrum suggest that increased attention should be paid to the stress that empathy can entail. This perspective may allow for the creation of similarly targeted interventions throughout the medical school curriculum to counteract the decline in empathy, the so-called "hardening of the heart," associated with physician-training worldwide.

Increasing Interest in Child and Adolescent Psychiatry in the Third-Year Clerkship: Results from a Post-Clerkship Survey

The authors aimed to determine whether a structured clinical experience in child and adolescent psychiatry (CAP) during the third-year psychiatry clerkship would impact interest in pursuing careers in psychiatry and CAP. The authors constructed and administered a postrotation survey, the Child and Adolescent Psychiatry Experiences Questionnaire (CAPE-Q), to evaluate clinical experiences and career interest in psychiatry and CAP both before and after a clerkship in psychiatry. The value of specific aspects of the clerkship to students' career decisions was also assessed. The students completed the surveys at the end of their psychiatry clerkship in the 2005-2006 academic year and in their first rotation of 2006-2007. Of the 98 respondents, the majority reported no change in interest in general psychiatry or in CAP after the clerkship. However, exposure to inpatient CAP correlated with increased interest in the field and in its influence on pursuing a CAP career. Interest in CAP positively correlated with agreement that the CAP clinical experience influenced their career decision. The influence of the CAP clinical experience on career decision was associated with interest in both psychiatry and CAP, as well as with change in CAP interest after the clerkship. These preliminary results suggest that the CAPE-Q may be useful for assessing students' clerkship experiences and the impact of these experiences on their decision to pursue a career in child psychiatry. Here, inpatient CAP experience led to increased interest in the field. The CAPE-Q could be used to identify students for whom electives and mentoring opportunities could be arranged. It could also be used in assessment of clerkship experiences.

Exposing Medical Students to Child and Adolescent Psychiatry: A Case-Based Seminar

Despite a documented shortage of child and adolescent psychiatrists, few studies have examined whether including child and adolescent psychiatry didactics in a medical school curriculum can stimulate appreciation and interest among students, possibly leading more students to choose careers in this specialty. The authors surveyed third-year medical students at the Feinberg School of Medicine of Northwestern University regarding their reactions to a 3-hour case-based seminar on child and adolescent psychiatry topics recently implemented as part of the general psychiatry clerkship. Student ratings reflected a positive view of the field and many students reported an increased likelihood of considering the specialty as a career after the seminar. In addition, students desired increased exposure to child and adolescent psychiatry while in medical school. Medical schools may consider providing students with increased exposure to child and adolescent psychiatry as this may encourage more future physicians to enter the field.

Use of an Audience Response System in an Evidence-Based Mini-Curriculum

ABSTRACT Since 2002, library faculty at the Indiana University School of Medicine have taught third-year medical students how to retrieve the best evidence from MEDLINE to address their clinical questions. In preparation for their Neurology, Medicine, and Psychiatry clerkships, students attended a review of evidence-based medicine principles and techniques for searching the literature. The session was team-taught by two faculty members, one from the Internal Medicine department and the other from the Library. The librarian reviewed important MEDLINE principles for constructing a good subject search and applying appropriate evidence-based filters. During the clerkships, students were asked to generate clinical questions arising from their patient encounters, searched MEDLINE for the best evidence, critiqued the results, and then applied them back to their patients' care. Library faculty provided individualized feedback on the student searches. A follow-up session two months later reinforced MEDLINE principles, used student searches as examples, and extended the discussion to other evidence-based, point-of-care resources. To add to the interactivity of the follow-up sessions, librarians used an audience response system to measure students' understanding of literature retrieval techniques and to gauge student preferences for information seeking on clinical topics. Overall, the sessions have been well-received by the students.

Do Clinical Evaluations in a Psychiatry Clerkship Favor Students With Positive Personality Characteristics?

The authors examine associations of personality characteristics, National Board of Medical Examiners subject examination performance, and Objective Structured Clinical Examination performance with clinical evaluations of third-year medical students in a psychiatry clerkship. Students completed the Revised NEO Personality Inventory, which measures personality domains of neuroticism, extraversion, openness, agreeableness, and conscientiousness and associated personality traits. At clerkship completion, students completed the National Board of Medical Examiners subject examination and a psychiatry Objective Structured Clinical Examination, and were evaluated by attending physicians (using a standardized evaluation form) regarding their clinical "knowledge and skill" and "interpersonal behavior." Data were analyzed using Pearson correlation and canonical correlation. National Board of Medical Examiners subject examination and Objective Structured Clinical Examination scores were uncorrelated with clinical evaluations of "knowledge and skill" and "interpersonal behavior." Personality variables explained a moderate amount of variance in clinical evaluations. "Knowledge and skill" was positively associated with the domain of conscientiousness, the extraversion trait of warmth, and the conscientiousness traits of competence and achievement striving. "Interpersonal behavior" was negatively associated with the neuroticism trait of angry hostility and positively associated with the domain of agreeableness; the extraversion traits of warmth, gregariousness, and positive emotions; and the agreeableness traits of trust, altruism, compliance, and tender-mindedness. Clinical evaluations of medical students may favor personality styles that reflect positive elements of extraversion, agreeableness, and conscientiousness. The present findings raise questions regarding the validity of clinical evaluation elements in clerkship performance appraisal.

What Troubles Clerks in Psychiatry? A Strategy to Explore the Question

The psychiatric clerkship is a stressful experience that influences attitudes toward patients with psychiatric illnesses and influences recruitment into the field. This study focused on medical students' encounters with patients they found troubling or difficult, and whether specific themes regarding their emotional responses could be identified. Third-year medical students rotating through the psychiatry clerkship participated in a problem patient conference for which they were required to submit a form detailing a troubling encounter that occurred with a patient in the prior week. During the conferences, students discussed these encounters and their responses to them. The encounters were later reviewed and grouped into a set of four themes. Comparisons were made between male and female students, and response to patients at the start and finish of the clerkship. For both male and female students the most common reaction of a problematic encounter was frustration/helplessness, followed by having a strong negative reaction, then identification with patients evoking a disturbing response, and finally feelings of intimidation and fear. There were no gender differences for any of the four categories. The proportion of encounters classified as intimidating/frightening significantly declined from the first half to the second half of the rotation. The problem patient conference is an effective tool to elicit candid concerns regarding the care of psychiatric patients and is an opportunity to empathically address struggles specific to the psychiatric clerkship.

Psychiatry Clerkship Objective Structured Clinical Examination is Here to Stay

Psychiatry Clerkship Objective Structured Clinical Examination is Here to Stay

Does a Clerkship in Psychiatry Affect Medical Students' Attitudes Toward Psychiatry?

Does a Clerkship in Psychiatry Affect Medical Students' Attitudes Toward Psychiatry?

Does a Clerkship in Psychiatry Contribute to Changing Medical Students' Attitudes Towards Psychiatry?

The psychiatric clerkship is perceived as an intervention point in medical students' attitude toward psychiatry and career choice after graduation. The authors aim to assess the impact of the psychiatric clerkship in students from Israeli and U.S. origin on their attitude toward psychiatry. A modified Nielsen's questionnaire was administered at the start and end of the clerkship in two groups of students. There was no statistically significant difference in attitude scores between the start and endpoint of a clerkship on both the Israeli and the United States groups. Item analysis did not reveal significant impact of clerkship. The psychiatry clerkship does not change students' view on the attitude assessed in this study, regardless of their origin (Israeli or U.S.). Further research is needed in order to find more clerkship-dependent contributors to positive or negative attitudes toward psychiatry.

Development and Implementation of an Innovative Ward-Based Program to Help Medical Students Acquire End-of-Life Care Experience

The authors developed and implemented a new ward-based end-of-life care experience for third-year medical students at Yale University School of Medicine, which began on a pilot basis in 2005. The primary objectives of the program, which still continues, are to improve students' comfort and skills in communicating with and assessing patients facing the end of life and to reflect on their experiences. Students interview a hospitalized patient, family, and caregivers; assess specified end-of-life domains and management plans; reflect on the experience; and then prepare a report for presentation at a case conference facilitated by dedicated multidisciplinary faculty. Many students interview patients while rotating on psychiatry consults, and the case conference occurs during the psychiatry clerkship. A total of 45 students in the pilot year (2005), 76 students in the following year, and 48 thus far in the current year have completed the program. An assessment of the personal impact of the exercise on the students who completed the program in 2005 and 2006 revealed six themes, including students' recognition of the complexity of patients' reactions to dying, students' appreciation of the value of the clinicians' presence, and students' personal reflections. This experience suggests that a hands-on end-of-life exercise is feasible and will be well received in the acute inpatient setting. Key features for success include separate, dedicated faculty for the case conference (which is integrated into a single clerkship), emphasis on student self-reflection, and a requirement that the written component become part of the student's portfolio.

Are Medical Students Assigning Proper Global Assessment of Functioning Scores?

This article seeks to determine whether medical students can estimate the appropriate score for the Global Assessment of Functioning (GAF) compared with psychiatry residents and staff psychiatrists. The authors hypothesized that medical students' estimations of GAF scores for patients in clinical vignettes would differ from those assessed by the psychiatry residents and staff psychiatrists. The authors designed a cross-sectional confidential survey of medical students, psychiatry residents, and staff psychiatrists. Consenting participants were asked to provide demographic information and then complete the accompanying questionnaire after reading two vignettes. One of the vignettes described a depressed patient and the other a psychotic patient. The subjects were asked to estimate the GAF scores for the patients in both vignettes. Then the subjects were given the GAF scoring guide to review and were asked to re-assess their initial GAF scores for the patients in the vignettes. Medical students assigned much higher GAF scores for the patient in the vignette with less severe symptoms than the psychiatry residents and staff psychiatrists. The GAF scores of all three groups for the patient in the vignette with more severe symptoms were comparable. The ability of medical students to assign proper GAF scores needs to be studied further. Our study suggests that current 1-month rotations in psychiatry, without specific training on assigning GAF scores, may not provide medical students with enough information to assess GAF scores accurately. This might need to be addressed in psychiatry clerkships.