EXPECTATIONS
OF AND FOR THE PSYCHIATRY CLERKSHIP DIRECTOR
Thomas W.
Kuhn, M.D., Mitchell Cohen, M.D., H. Jonathan Polan, M.D., E. Cabrina Campbell,
M.D., Kathleen A. Clegg, M.D, Amy C. Brodkey, M.D.
Submitted for Publication on July 26,
2000
ABSTRACT
Despite the rich history of the
clinical clerkship, the duties and responsibilities of the clerkship director
have not been fully and uniformly characterized. In this position paper, which has been approved by the Council of
the Association of Directors of Medical Student Education in Psychiatry
(ADMSEP), the authors review the relevant literature and propose standards
regarding the expectations of and for the psychiatry clerkship director
(PCD). The standards address issues of
qualifications, duties and competencies in the areas of leadership,
administration, education, mentoring, and scholarship, as well as the resources
of time, administrative assistance, budget, and compensation required in order
to carry out these duties.
INTRODUCTION
William Osler developed the
first American clinical clerkship at Johns Hopkins in 1896. Unlike other U.S.
medical schools of the time, Hopkins required medical students to have direct
patient care responsibility (1).
Flexner endorsed this as a standard for all medical schools (2). In
order to allow for widespread implementation of this model, the position of
clerkship director emerged. In recent
years, at least seven national organizations devoted to medical student
clerkships have developed (3). These
organizations have joined together to form the Alliance for Clinical Education
(ACE), whose mission is to foster collaboration across specialties to promote
excellence in clinical education of medical students.
Despite the rich history of
the clinical clerkship, the duties and responsibilities of the clerkship
director (CD) have not been fully and uniformly characterized. The current scarcity of resources for
undergraduate medical education confers urgency on this task. A number of surveys of CDs’ age, gender,
academic rank, and time spent in various activities have been done (4-7). Pangaro proposed standards for proficiency
and productivity of, as well as resources to be allocated to, CDs in internal
medicine (8). These were endorsed by
the Clerkship Directors in Internal Medicine Council and the Association of
Professors of Medicine Executive Council.
Duties and needs of the CD have been addressed in the ACE/Association of
American Medical Colleges (AAMC) sponsored publication, Handbook for
Clerkship Directors and in a chapter on psychiatric clerkships in the Handbook
of Psychiatric Education and Faculty Development (9, 10).
All 126 U.S. medical schools require their students
to complete a clinical clerkship in psychiatry (11). This clerkship has taken on increased importance as the clinical
practice of medicine evolves. Studies
have shown that 25-30% of patients in primary care settings have a diagnosable
psychiatric disorder (12, 13, 14).
Despite this, there is under recognition of psychiatric conditions (15,
16). Even for those students not
intending to pursue a primary care career, clinical training in psychiatry is a
necessary part of a general medical education (17).
In order to achieve clarity
and consensus and to convey relevant standards, the Association of Directors of
Medical Student Education in Psychiatry (ADMSEP) convened an ad hoc task force
to develop this position paper on the expectations of and for the psychiatry
clerkship director (PCD). This paper
was distributed to the entire ADMSEP membership for review, and was endorsed by
the ADMSEP Council.
QUALIFICATIONS
The PCD must be an excellent
and broadly knowledgeable clinician. He or she should have experience with
clinical supervision and classroom instruction of medical students and have
ability and investment in teaching. The PCD should possess the administrative
skills to manage the clerkship. Prior experience as a clerkship site
coordinator, assistant clerkship director, or assistant director of medical
student education is desirable but not mandatory.
The PCD must develop
familiarity with principles of instructional design, valid and reliable
assessment, the curriculum priorities of the department and school, and
national curriculum standards.
Essential personal qualities include enthusiasm for the work,
accessibility, ability to communicate clearly and convey feedback, and a
passion for learning. Since the PCD places demands on colleagues without direct
influence on their compensation or other incentives, she or he must have
interpersonal skills and intellectual authority as an educator in order to
persuade faculty to teach.
Although many psychiatric educators currently do not
conduct educational research, it is becoming increasingly expected that they
will do so. Therefore, interest and
skills in educational research methodologies are desirable. A knowledge of postgraduate programs can be
very helpful in order to provide career counseling to medical students. These competencies may not all be present in
a new PCD, and mentorship by the director of medical student education, chair,
and education dean is essential in developing these skills.
DUTIES
AND COMPETENCIES
The position of PCD consists
of multiple duties, some of which overlap.
These duties can be classified into five critical domains: leadership,
administration, education, advising/mentoring, and scholarship. These are summarized in Table 1.
Leadership
As defined by Kotter,
leadership is the ability to develop a vision of the future, align people with
that vision, and inspire them to make it happen despite obstacles (18). For the
clerkship director, the people involved include medical students, teaching
faculty, the chair, departmental director of medical student education, CDs
from other departments, the dean, and medical school committees. In concert
with the chair and other faculty, the PCD develops a vision and goals for the
clerkship, and is the key element in the realization of that vision.
The PCD has the additional
challenge of presenting a specialty to non-psychiatric colleagues. All specialties are unique in their own way,
but psychiatry is at particular risk of being misunderstood. Since our specialty has a rich but often
confusing and divisive heritage of pluralism, the PCD, chair, and other
departmental educators must develop and present a coherent view of the field
(19). This includes educating faculty
in other departments and administrators about the value of a psychiatric
perspective to the practice of clinical medicine.
Administration
The PCD is responsible for a
full-time clinical training experience for 50-250 medical students per
year. This demands that the PCD
organize the schedules and clinical assignments of the students, coordinate
these with departmental faculty and the dean’s office and monitor compliance
with medical school policies (10). The
PCD must ensure that formative and summative evaluations are completed on all
students, that grades are reported to the medical school, and that students at
all training sites receive an equivalent educational experience that is
consistent with clerkship goals. The
PCD needs to establish standards for evaluating students, individual faculty,
and sites, and convey these to the students and faculty. These tasks require the PCD to manage
personnel, budgets, and office space (20).
The PCD interacts with
colleagues in the department, medical school, and affiliates on a regular
basis. (Fig 1) The administrative
responsibilities of the PCD are large, but the administrative authority over
faculty and residents is indirect, both at the medical school and at affiliated
institutions. The PCD only has direct
authority medical students and educational support staff, and even the authority
over the students is partial, overridden periodically by other curricular
demands, the registrar, promotions committee, curriculum committee, etc.
Administrative work with the residency training director, student promotions
committee, and curriculum committee is collaborative. Since the PCD has few resources of funding or space to
distribute, she or he must exert influence indirectly, through interpersonal
skills, intellectual authority, and by providing feedback to the director of
medical student education, chair, dean, and promotion and tenure committees.
Education
The PCD must develop a
curriculum based on local needs and resources and national standards, such as
the ADMSEP Educational Objectives for a Junior Psychiatry Clerkship (21,
22). The PCD must then use available
resources to provide a series of clinical and didactic experiences that allows
students to meet these objectives. He or she must also develop and implement
strategies to assess whether the students have achieved the stated objectives
of the clerkship (23, 24). In order to
maintain credibility and contact with the faculty and trainees, the PCD must be
a major teacher in the clerkship and other departmental teaching programs (10).
The PCD should foster the
exchange of ideas, information, and innovation across and between levels of the
training hierarchy, contributing to an atmosphere of intellectual curiosity and
lifelong learning. She or he should encourage peer learning among students and
among internal, affiliate, and external faculty. The PCD should collaborate with the director of the preclinical
psychiatric curriculum to provide continuity in curricular process and content. The PCD should also collaborate with the
residency training director and other faculty to facilitate teaching and
scholarship down the educational continuum, from faculty to students and
residents to students (10, 25). (Fig 2)
The roles of interns, residents, and attendings in medical student education
are complementary, and this clinical teaching has a demonstrable effect on
medical student learning (26, 27).
Mentoring
and Advising
The PCD’s office is often a focal point for
individual career counseling, advising, and mentoring of students and junior
faculty (28, 29). The PCD must be
available, and engender trust. A broad
knowledge of training programs and career options is useful. For students interested in further
psychiatric training, the PCD should enthusiastically recommend electives,
research experiences and (for qualified candidates) psychiatry
residencies. The PCD must also identify
and counsel students with deficits of knowledge or skills, but must avoid
diagnosing or treating students (30).
Scholarship
The PCD should engage in
scholarly activity related to education. This includes presentation at
professional meetings, publication (including abstracts and posters, books or
book chapters, and peer-reviewed papers), and committee service in the medical
school and relevant local and national organizations. Psychiatry must follow the lead of internal medicine, in which
44% of CDs conduct educational research (5).
PCDs currently spend a mean of 5.9 hours per week on research, though it
is not clear how much of that is educational research (6). Both the AAMC and the American Medical
Association encourage educational research in medical schools (17). The breadth and scope of an individual PCD’s
scholarly work should increase as the tenure of the PCD increases.
RESOURCES
The strong support of the
chair is critical for the PCD to develop and maintain a high quality
educational program. This should
include access to the chair and regular meetings to discuss the clerkship and
related medical school issues (9).
There may be other levels of departmental educational leadership,
including director of medical student education and vice-chair of education. If
so, all of these individuals should collaborate to develop clerkship
goals. The costs of providing medical
student education must be considered when establishing these goals. AAMC acknowledges these incremental costs in
its publication Structures and Functions of a Medical School, which
states, “Planning for educational innovation should consider the
incremental resources that will be required (17).“
Time Allocation
The PCD must be given
adequate time for the many clerkship-related activities, which are specified in
Table 1. Current time allocations for
clerkship directors in Pediatrics, Psychiatry, Obstetrics and Gynecology, and
Medicine have been studied (4,5,6,7). The results are summarized in Table
2. Although the time allocation for
pediatric clerkship directors is quite low, they reported that more time would
be preferable. Our analysis of the
duties of the PCD makes the necessity for these allocations clear and supports
the adoption of prevailing practice as policy.
Specifically, we recommend an allocation of 20% full-time equivalent
(FTE) for clerkship administration, 25% FTE for direct teaching, and 10% FTE
for educational research or other education-related scholarly work, for a total
of 55% of time devoted to clerkship-related activities. This is consistent with the recommendation
of the Association of Professors of Medicine that a minimum of 50% FTE
be allotted to the position of CD if personal teaching and scholarly activity
were expected (8). These time
allocations are also consistent with guidelines for mission-based budgeting
that were published in Academic Medicine in 1999 (31). Under these guidelines, a clerkship director
is allotted 20% time for clerkship administration, plus time for the direct
teaching of students. The recommended
time allocation may need to be adjusted at individual institutions, to account
for variation in class size, number of clerkship sites, etc. PCDs with additional medical student
responsibilities, such as director of medical student education, require more
protected time. The funding for the
position of an individual PCD may come from several sources. For example, the PCD’s teaching effort may be
funded by the hospital, while the school of medicine may fund the
administrative effort.
Administration
The large number of
administrative tasks requires substantial access to secretarial and
administrative support. Phelan
recommends a full-time administrative assistant whose time is primarily
assigned to the CD (20). Individual
institutions may vary, but published guidelines have recommended that 75 to
100% of the administrative assistant’s time be devoted to the psychiatry
clerkship (10, 28). Clerkships with
multiple sites need additional administrative assistance for the site
directors. Duties of the administrative
assistant are outlined in Table 3.
Space, furniture, and office
supplies need to be allocated for the PCD and staff (20). A computer with Internet access is needed
for scheduling, word processing, data collection and analysis, and
collaboration and communication with colleagues via e-mail, websites, and
listserves. At a minimum, the software should
include programs for word processing, spreadsheets and presentations, a
statistical package, and a reference manager.
Psychiatry clerkship
directors should have access to a biostatistician and a master’s level or Ph.D.
educator who assists with curricular design, scoring and evaluation of
examinations, analysis of course evaluation data, and educational research
(20). These individuals may be dedicated to the department, or may work out of
the dean’s office or office of medical education to provide consultations to
many departments.
Budget
To be an effective manager,
the PCD should have access to, and be accountable for, a budget to support
direct student costs, faculty needs, clerkship administration, and awards for
students and faculty (10, 20). Direct
student costs include printed materials, standardized patients, videotaped
materials, computerized instructional materials, testing materials, and
honoraria for outside teachers. PCDs
are often responsible for the psychiatry club or interest group, which also
requires funding. To maintain
intellectual mastery of clinical and educational issues, the PCD should be
provided with support for dues for relevant professional organizations and
travel to critical meetings such as the annual meeting of ADMSEP and other
educational organizations (25). The PCD needs access to general and
subspecialty psychiatry journals, as well as Academic Medicine, Academic
Psychiatry, and The Journal of the American Medical Association, as
well as the Handbook of Psychiatric Education and Career Development,
and the Handbook for Clerkship Directors (25). PCDs play a crucial role in faculty development and morale, and
need budget allowances for faculty retreats, workshops, and other
organizational meetings related to medical student education.
Compensation and
Professional Development
In order to create an
expectation of educational excellence, the PCD, department chair, and medical
school dean must develop a system to acknowledge and compensate faculty for
educational excellence. This may
include promotions, raises, travel, or budgetary support for new
initiatives. The concept of
mission-based budgeting may provide the framework for such a system (31). In an era of increased fiscal
accountability, schools of medicine must monitor productivity of faculty and
staff, and ensure that dollars allocated for education go to support effective
educators and programs.
The professional development
of the PCD is dependent upon proper mentoring and supervision. The chair should be expected to mentor the
PCD with the eventual goal of moving into more senior positions in the
department or medical school (8, 25).
An apprenticeship as assistant director of medical student education is
a logical starting point. The new PCD
should be provided with the opportunity to attend a new clerkship director’s
course, and to receive additional training in educational design and research
(8). The PCD should also be mentored by
more senior educators, within the department or elsewhere, including direct
observation and formal feedback regarding the PCD’s teaching.
SUMMARY
Osler’s clinical clerkship
remains a cornerstone of medical student education, but the 20th
century has brought many changes and challenges for medical education and the
practice of clinical medicine. As we
enter the 21st century, medical schools will need to reaffirm their
commitment to medical student education and make corresponding changes in the
academic culture (32). The educational budget must be tied to the educational
mission.
Psychiatric disorders are
very common, and often underrecognized in the primary care setting. Changes in the health care delivery system
mandate that prospective generalists be given sound training and skills in recognizing
and treating mental illness (33). The
psychiatry clerkship may be the last formal education in psychiatry that many
physicians receive (22). It is
therefore more important than ever that the duties of the PCD are clearly
spelled out and that he or she is provided with sufficient resources to carry
out those duties.
The position of PCD requires
a minimum of 55% FTE if leadership, scholarly activity, mentoring and advising,
and the development of innovative educational programs are desired. The PCD should be provided with an assistant,
most or all of whose time is devoted to the clerkship. The PCD also needs access to adequate space,
supplies, budget, and consultants in educational design, assessment, and
research. To maintain high-quality
education, PCDs, their chairs, and deans must develop ways to acknowledge and
compensate faculty for educational excellence.
We have reviewed the current
literature regarding the roles and needs of an effective PCD, while
simultaneously taking into account the shifting ground of educational funding. As in all areas of academic medicine,
considerable change and evolution lies ahead for the role of PCD. In this context, it will be critical to
preserve the core PCD missions of leadership, administration, education,
mentoring, and scholarship.
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RME: The clerkship director, in Handbook for Clerkship Directors, edited by
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AAMC Curriculum Directory. Washington
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JE, Barrett JA, Oxman TE, et al: The prevalence of psychiatric disorders in a
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PR, Slavney PR: Perspectives of Psychiatry.
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Fincher RME: Administration of the clerkship, in Handbook for Clerkship
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TWK 7/26/00 5:00PM
Table 1- Duties and Competencies of the Clerkship
Director
|
|
·
Leadership
- Incorporates departmental view of contemporary
clinical psychiatry into curriculum - Provides overall vision for the clerkship mission in
collaboration with chair and key faculty - Motivates colleagues to teach - Presents psychiatry as a specialty to
non-psychiatric colleagues - Demonstrates broad clinical psychiatric skills and
familiarity with educational theory/practice - Encourages peer learning and education along the
training hierarchy ·
Administration
|
Modified
from Brodkey, AC and Sierles, FS, “Psychiatric Clerkships” (Tables 13-1 and
13-2, pp 256-257) in Kay, J, Silberman, EK, and Pessar, L, Handbook of
Psychiatric Education and Faculty Development (1999) APPI. Washington, DC.
Table
2- Time Allocation of Clerkship Directors
|
Author |
Number
of clerkship directors responding |
Specialty |
Time devoted to |
Total
time devoted to clerkship |
|||
|
Administration |
Teaching |
Research |
Other |
||||
|
Greenberg,
1995 |
100 |
Pediatrics |
15% |
10% |
1% |
2% |
28% |
|
Sierles,
1996 |
107 |
Psychiatry |
22% |
26% |
11% |
0% |
59% |
|
Magrane,
1997 |
199 |
Ob/Gyn |
18% |
24% |
6% |
0% |
48% |
|
Fincher,
1997 |
229 |
Medicine |
26% |
28% |
8% |
0% |
62% |
Table 3- Duties of the Administrative Assistant
(Clerkship Coordinator)
|
|
-
Schedules
classes, reserves classrooms, and obtains audiovisual and other equipment
- Orders supplies (scantron answer sheets, markers for
board/overhead, slide trays, etc) - Makes clinical assignments - Prepares written materials - Distributes keys and meal tickets, fields questions,
relays messages, and handles crises - Proctors and grades exams - Tracks evaluation and maintains students records and
databases for research and evaluation - Communicates with Dean’s Office, Office of Medical
Education, other clerkship administrators - Provides a sympathetic ear to students and
information to the clerkship director |
Modified
from Brodkey, AC and Sierles, FS, “Psychiatric Clerkships” (Table 13-2, pp
256-257) in Kay, J, Silberman, EK, and Pessar, L, Handbook of Psychiatric
Education and Faculty Development (1999) APPI. Washington, DC.
Figure 1
Clerkship Director: Administrative
Responsibilities
Figure 2
PCD Educational Leadership:
Facilitation of Learning &
Educational Scholarship
PCD must serve as catalyst for learning and
scholarship between peers (horizontal lines) and along the educational
hierarchy (vertical lines). PCD may
run Residents as Teachers seminars, organize problem-based learning
training/teaching programs, etc., and model openness to input from all
levels to fulfill this role.
SOM
RI
PCD
Faculty
PCD
Affiliate Site Directors
PCD
External
Colleagues
Peer Learning &
Educational Development
Educational
Hierarchy
SOM RI: School of Med. Research Infrastructure
PCD
PCD
Students
Students
Residents
Residents
|
Figure 1 Clerkship Director: Administrative
Responsibilities |
|
Figure 2 PCD Educational Leadership: Facilitation of Learning &
Educational Scholarship |
|
PCD must serve as catalyst for learning and scholarship between peers (horizontal lines) and along the educational hierarchy (vertical lines). PCD may run Residents as Teachers seminars, organize problem-based learning training/teaching programs, etc., and model openness to input from all levels to fulfill this role. |
|
SOM RI |
|
PCD |
|
Faculty |
|
PCD |
|
Affiliate Site Directors |
|
PCD |
|
External Colleagues |
|
Peer Learning & Educational Development |
|
Educational Hierarchy |
|
SOM RI: School of Med. Research Infrastructure |
|
PCD |
|
PCD |
|
Students |
|
Students |
Residents |
Residents |
|
|
|
|