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






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.




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.




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.



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.




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.




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.




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).



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.




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.




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.




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.




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.



1.       Huddle TS, Ende J: Osler’s clinical clerkship: origins and interpretations. J Hist Med Allied Sci 1994; 49:483-503.


2.       Flexner, A: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching.  New York, Carnegie Foundation for the Advancement of Teaching, 1910.


3.       Fincher RME: The clerkship director, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.


4.       Magrane DM, Fenner D: A profile of directors of clerkships in obstetrics and gynecology in the United States and Canada. Obstet Gynecol 1997; 89:785-9.


5.       Fincher RM, Lewis LA: Profile of medicine clerkship directors. Acad Med 1997; 72 (Suppl):S112-4.


6.       Sierles FS, Magrane D: Psychiatry clerkship directors: who they are, what they do, and what they think. Psychiatr Q 1996; 67:153-62.


7.       Greenberg L, Sahler OJZ, Siegel B, et al: The pediatric clerkship director. Support systems, professional development, and academic credentials. Arch Pediatr Adolesc Med 1995; 149:916-20.


8.       Pangaro LN: Expectations of and for the medicine clerkship director. Am J Med 1998; 105:363-5.


9.       Fincher RME: Handbook for Clerkship Directors. Washington DC, Association of American Medical Colleges, 1996.


10.   Brodkey AC, Sierles FS: Psychiatric clerkships, in Handbook of Psychiatric Education and Faculty Development, edited by Kay J, Silberman EK, Pessar L.  Washington DC, American Psychiatric Press, 1999.


11.   1998-1999 AAMC Curriculum Directory.  Washington DC, Assocaition of American Medical Colleges, 1998.


12.   Von Korff M, Shapiro S, Burke JD, et al: Anxiety and depression in a primary care clinic.  Comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessments.  Arch Gen Psychiatry 1987; 44(2): 152-6.


13.   Schulberg HC, Burns BJ: Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions.  Gen Hosp Psychiatry 1988; 10(2): 79-87.


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17.   Functions and Structure of a Medical School. Washington DC, Association of American Medical Colleges, 1997.


18.   Kotter JP: Leading Change. Boston, Harvard Business School Press, 1996.


19.   McHugh PR, Slavney PR: Perspectives of Psychiatry.  Baltimore, Johns Hopkins Press, 1983.


20.   Phelan S, Fincher RME: Administration of the clerkship, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.


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26.   Griffith CH, Wilson JF, Haist SA, et al: Do students who work with better housestaff in their medicine clerkships learn more?  Acad Med 1998;73:S57-9.


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28.   Sierles FS: Faculty development, in the clerkship and in general, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.


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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

-       Provides a full-time clinical experience for every student in the medical school

-       Oversees production and distribution af all schedules

-       Recruits new teaching affiliates and maintains ongoing affiliations

-       Recruits new faculty into teaching roles

-       Monitors the effectiveness of all clinical sites, faculty, and the clerkship in achieving its goals

-       Ensures that timely formative and summative evaluations are provided to all students

-       Serves on relevant medical school education and evaluation committees

-       Serves as a link between department, Dean’s Office, other clerkship directors, and all clinical sites

-       Delivers narrative evaluations and final grades to Dean’s Office

-       Implements changes in clerkship mandated by department, medical school, or LCME

-       Manages support personnel, educational budget, office space

·       Education

-       Sets core educational goals for the clerkship

-       Prepares students to evaluate and treat, or refer, patients with common psychiatric disorders

-       Develops curriculum based on local needs, national standards, and departmental vision

-       Establishes mandatory duties and assignments for students (call nights, papers, etc.)

-       Delivers strong didactic presentations and clinical teaching

-       Establishes and conveys standards for student participation in patient care at clinical sites

-       Ensures that myths of psychiatric illness are acknowledged, discussed, and dispelled

-       Develops overall assessment strategy for students, prepares and implements all examinations

-       Develops plan and instruments for evaluation of program’s success in meeting clerkship goals

·       Mentoring/Advising

-       Fosters personal growth and professional development of students

-       Provides career guidance to medical students

-       Maintains knowledge of local and national career options

-       Counsels students with inadequate knowledge base or skills and plans remediation

-       Collaborates with and encourages residents and junior faculty interested in teaching

-       Models and facilitates life-long learning and openness to feedback

·       Scholarship

-       Demonstrates educational innovation and research as evidenced by:

-       Presentations at national meetings

-       Published abstracts and exhibited posters at academic meetings

-       Peer-reviewed papers, book chapters, monographs, and books

-        Committee service in medical school, local, and national organizations

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


Number of clerkship directors responding


Time devoted to

Total time devoted to clerkship





Greenberg, 1995








Sierles, 1996








Magrane, 1997








Fincher, 1997














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

-       Assists in preparation of faculty performance evaluations for appointment, promotion, and teaching awards


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.

Text Box: PCD










Affiliate Site Directors







Peer Learning &

Educational Development





SOM RI: School of Med. Research Infrastructure

Text Box: PCDText Box: PCDText Box: PCD