3321 words + three tables

Corresponding Author: Thomas Kuhn

(313) 576-4913

tkuhn@med.wayne.edu

 

 

TITLE: STANDARDS FOR PSYCHIATRY CLERKSHIP DIRECTORS

AUTHORS:

Thomas W. Kuhn, M.D., Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI

Mitchell J.M. Cohen, M.D., Department of Psychiatry and Human Behavior, Jefferson Medical College, Philadelphia, PA

H. Jonathan Polan, M.D., Department of Psychiatry, Weill Medical College of Cornell University, New York, NY

E. Cabrina Campbell, M.D., Department of Psychiatry, University of Pennsylvania, Philadelphia, PA

Kathleen A. Clegg, M.D., Department of Psychiatry, Case Western Reserve University, Cleveland, OH

Amy C. Brodkey, M.D., Department of Psychiatry, University of Pennsylvania, and Friends Hospital, Philadelphia, PA

 

Address reprint requests to:

Thomas W. Kuhn, M.D.

Mental Health Clinic 11MH

Veteran’s Administration Medical Center

4646 John R

Detroit, MI 48201

                                                                        Key Words: psychiatry,  clinical clerkship,                                                                                               organization and administration
ABSTRACT

The authors review the literature relevant to the position of Psychiatry Clerkship Director (PCD) and propose standards regarding the expectations for this position. The standards address 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 to carry out these duties. This paper has been endorsed by the Council of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), by the American Psychiatric Association’s Committee on Medical Student Education, and by the Executive Committee of the American Association of Chairmen of Departments of Psychiatry.

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 (CD) 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), with the mission of fostering collaboration across specialties to promote excellence in clinical education of medical students. 

The value of the psychiatry clerkship in medical student education is widely recognized.  All 126 U.S. allopathic medical schools require their students to complete a clinical clerkship in psychiatry (4).  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 (5,6,7).  Despite this, there is underrecognition of psychiatric conditions in the primary care setting (8,9).  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 (10). 

Historically, the primary mission of medical schools was education.  In the post World War II period, American medical schools evolved into large and highly complex institutions with multiple missions (11).  Attempts to rationally allocate resources to support these missions have led to the concept of mission-based budgeting (12).  This requires that faculty roles be clearly defined. The duties and responsibilities of the psychiatry clerkship director (PCD) have not previously been fully and uniformly characterized, although some efforts have been made.  For example, a number of surveys of CDs’ age, gender, academic rank, and time spent in various activities have been done (13, 14, 15, 16).  Pangaro proposed standards for proficiency and productivity of, as well as resources to be allocated to, CDs in internal medicine (17).  Various aspects of the CD position 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 (18, 19).

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 PCD.  This paper was distributed to the ADMSEP membership for review, and has been endorsed by the ADMSEP Council, by the American Psychiatric Association’s Committee on Medical Student Education, and by the Executive Committee of the American Association of Chairmen of Departments of Psychiatry.

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QUALIFICATIONS

The PCD should be a board-certified psychiatrist, unless, in exceptional cases, a department’s most qualified clinician/educator is a non-physician. He or she should have experience with clinical supervision and classroom instruction of medical students and have abilities and an investment in teaching. In order to develop the administrative skills necessary to manage the clerkship, prior experience as a clerkship site coordinator, assistant clerkship director, or assistant director of medical student education is desirable.

It is important that the PCD 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 teaching.  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.  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 duties of the PCD can be classified into five 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 (20). In concert with the chair and the medical student education committee, the PCD develops a vision for the clerkship, and is the key element in the realization of that vision. The people involved in actualizing this vision and who require inspiration from the PCD are diverse and include medical students, teaching faculty, the chair, departmental director of medical student education, CDs from other departments, the dean, and medical school committees

The PCD has the additional challenge of presenting psychiatry to non-psychiatric colleagues.  All specialties are unique, 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 (21).  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.  The PCD organizes the schedules and clinical assignments of the students, coordinates these with departmental faculty and the dean’s office and monitors compliance with medical school policies (19).  The PCD ensures 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.  In collaboration with the medical student education committee and other departmental leaders, the PCD establishes standards for evaluating students, individual faculty, and sites, and conveys these to the students and faculty.  These tasks require the PCD to manage personnel, budgets, and office space (22).

The PCD interacts with colleagues in the department, medical school, and affiliates on a regular basis.  The administrative responsibilities of the PCD are substantial, but the administrative authority over faculty and residents is indirect, both at the medical school and at affiliated institutions.  Since the PCD has few resources of funding or space to distribute, she or he exerts 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 develops and delivers a set of clinical and didactic experiences based on local needs and resources as well as national standards, such as the ADMSEP Educational Objectives for a Junior Psychiatry Clerkship (23, 24).  He or she also develops and implements strategies to assess whether the students have achieved the stated objectives of the clerkship (25, 26).  In order to maintain credibility and contact with the faculty and trainees, the PCD should be a major teacher in the clerkship and other departmental teaching programs (19).  

The PCD fosters 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 collaborates with the director of the preclinical psychiatric curriculum to provide continuity in curricular process and content.  She or he also collaborates with the residency training director and other faculty to facilitate teaching and scholarship along the educational continuum, from faculty to students and residents to students (19, 27).  Interns, residents, and attendings have complementary roles in the clinical training of medical students, and all have a demonstrable effect on medical student learning (28, 29).

Advising and Mentoring

Because the PCD’s office is often a focal point for individual career counseling, advising, and mentoring of students and junior faculty, she or he must be available and engender trust (30, 31). For students interested in further psychiatric training, the PCD recommends electives, research experiences and (for qualified candidates) psychiatry residencies.  A broad knowledge of training programs and career options nationwide is useful.  He or she prepares the students for the emotional reactions that may develop during the clerkship.  The PCD identifies and counsels students with deficits of knowledge or skills, but should avoid diagnosing or treating these students or any student for which the PCD provides clinical supervision or summative evaluation (32).

Scholarship

Both the AAMC and the American Medical Association encourage educational research in medical schools (10).  To ensure that the position of PCD is viewed as part of the academic enterprise of the department, it is advisable that he or she engage in scholarly activity related to education. This may include 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.

RESOURCES

The strong support of the chair is critical for the PCD to develop and maintain a high quality educational program.  This support should include access to the chair and regular meetings to discuss the clerkship and related medical school issues (18).  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 work collaboratively.

Time Allocation

Current time allocations for clerkship directors in pediatrics, psychiatry, obstetrics and gynecology, and internal medicine have been studied (13, 14, 15, 16). 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 (16).  Our analysis of the duties of the PCD makes the necessity for these allocations clear and has led us to 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.  The recommended time allocation may need to be adjusted at individual institutions, to account for variation in class size, number of clerkship sites, etc.  This recommendation is consistent with that 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 (17).  This time allocation is also consistent with the guidelines for mission-based budgeting published in Academic Medicine in 1999 (12).  Under these guidelines, a clerkship director is allotted 20% time for clerkship administration, plus time for the direct teaching of students (scholarly activity is not accounted for in this model).  PCDs with additional medical student responsibilities, such as director of medical student education, require more protected time. 

Administration

Phelan recommends a full-time administrative assistant whose time is primarily assigned to the CD (22).  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 (19, 30).  Clerkships with multiple sites need additional administrative assistance for the site directors.  Duties of the administrative assistant are outlined in Table 3.   

The PCD 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 (22). 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.

The PCD and support staff require space, furniture, and office supplies and equipment, including computers with internet access, an office software package, a statistical package, and a reference manager (22).

Budget

The PCD should have access to, and be accountable for, a budget to support direct student costs, faculty development, clerkship administration, and awards for students and faculty (19, 22).  Direct student costs include printed materials, standardized patients, videotaped materials, computerized instructional materials, testing materials, and honoraria for outside teachers.  PCD development is fostered by support for dues for relevant professional organizations and travel to critical meetings such as the annual meeting of ADMSEP and other educational organizations (27).  He or she also needs access to general and subspecialty psychiatry journals, as well as Academic Medicine, Academic Psychiatry, the Handbook of Psychiatric Education and Faculty Development, and the Handbook for Clerkship Directors (27).  Development of other faculty is fostered by retreats, workshops, and other organizational meetings related to medical student education.

Compensation and Professional Development

Educational excellence is facilitated if the PCD, department chair, and medical school dean develop a system to acknowledge and compensate faculty for educational excellence.  This may include promotions, raises, travel, or budgetary support for new initiatives.  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 by the chair as well as by more senior educators, within the department or elsewhere (17, 27).  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 (17). Salary support for 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.

 

SUMMARY

Osler’s clinical clerkship remains the cornerstone of medical student education, but the 20th century 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.

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).  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 medical student education, PCDs, their chairs, and deans must develop ways to acknowledge and compensate faculty for educational excellence.  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.

 

 

 

 

REFERENCES

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

5.       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.

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

7.       Barrett JE, Barrett JA, Oxman TE, et al: The prevalence of psychiatric disorders in a primary care practice.  Arch Gen Psychiatry 1988; 45(12): 1100-6.

8.       Jencks SF: Recognition of mental distress and diagnosis of mental disorder in primary care.  JAMA 1985; 253:1903-7.

9.       Borus JF, Howes MJ, Devins NP, et al: Primary health care providers’ recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 1988; 10:317-21.

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

11.   Abrahamson S: Time to return medical schools to their primary purpose: education. Acad Med 1996; 71:343-7.

12.   Watson RT, Romrell LJ: Mission-based budgeting: removing a graveyard. Acad Med 1999; 74:627-40.

13.   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.

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

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

16.   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.

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

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

19.   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.

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

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

22.   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.

23.   McCurdy FA: Creating a clerkship curriculum, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.

24.   Brodkey AC, Van Zant K, Sierles FS: Educational objectives for a junior psychiatry clerkship. Academic Psychiatry 1997; 21:179-204.

25.   Magarian GJ: Evaluating and grading students on clerkships, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.

26.   Templeton B: Evaluation of students, in Handbook of Psychiatric Education and Faculty Development, edited by Kay J, Silberman EK, Pessar L.  Washington DC, American Psychiatric Press, 1999.

27.   Kay J: Development as an educator, in Handbook of Psychiatric Education and Faculty Development, edited by Kay J, Silberman EK, Pessar L.  Washington DC, American Psychiatric Press, 1999.

28.   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.

29.   Tremonti LP, Biddle WB: Teaching behaviors of residents and faculty members. J Med Educ 1982;57:854-9.

30.   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.

31.   Feldmann TB: Undergraduate electives and special activities, in Handbook of Psychiatric Education and Faculty Development, edited by Kay J, Silberman EK, Pessar L.  Washington DC, American Psychiatric Press, 1999.

32.   Fincher RME, Morrison G: Working with students, including those with problems, in Handbook for Clerkship Directors, edited by Fincher RME. Washington DC, Association of American Medical Colleges, 1996.

33.   Association of American Medical Colleges’ Policy on the Generalist Physician.  Acad Med 1993;68:1-6.

Twk 5/21/01 12:45pm

 

 


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

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

-          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.