Educational Objectives for a Junior Psychiatry Clerkship

Amy C. Brodkey, M.D.
Dr. Brodkey is clinical associate professor and Dr. Van Zant is clinical associate professor; both in the Department of Psychiatry, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania.

Kristin Van Zant, M.D.
Clinical Associate Professor

Frederick S. Sieries, M.D.
Professor and chair, Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences, The Chicago Medical School, North Chicago, Illinois.

Explicit instructional objectives have become essential in medical education and have been developed nationally for students in surgery, gynecology, and pediatric clerkships. The authors describe the rationale for and process of developing psychiatry clerkship ob-jectives, first at the Medical College of Pennsylvania (MCP) and then by the Association of Directors of Medical Student Education in Psychiatry. Faculty interviews about the development of psychiatry clerkship objectives at MCP illustrate the objectives' positive educational impact. (Academic Psychiatry 1997; 21:179-204).

In recent years, the demand for explicit learning objectives in medical education has escalated because of expectations of licensing agencies and curriculum committees. Departments must specify the goals of their teaching and assess competence using such objectives (1). Model clerkship curricula have been developed by the Association for Surgical Education, the Association of Professors of Gynecology and Obstetrics, and the Council on Medical Student Education in Pediatrics.

There are two other compelling reasons to formulate psychiatry clerkship objectives. Despite modern psychiatry's rich clinical and scientific database, the perception of the psychiatrist as a physician who "knows nothing and does nothing" is still prevalent, as is the notion of mental illness as ill-defined, trivial, caused by weak character, or untreatable. Students interested in the field are often discouraged or disparaged (2,3). A document conveying the breadth and depth of what we teach could help correct some of these misperceptions.

Finally, for many future generalists, the junior clerkship is the last formal educational experience in psychiatry. Studies of mental disorders in primary care document both their high prevalence (4) and deficiencies in their recognition and treatment (5,6), with negative implications for patient outcomes (7,8). Although many reasons for these findings have been advanced, deficiencies in interview technique and knowledge of psychiatry likely contribute (9,10). Current changes in health care delivery mandate that we impart to prospective generalists substantial knowledge and skill in psychiatry, and we must state specifically what that knowledge and skill should be (11). Objectives can direct students' efforts toward the patient problems they are most likely to encounter in the future (12,13).

We describe the development of psychiatry clerkship objectives, first at the Medical College of Pennsylvania (now MCP-Hahnemann School of Medicine) and later for the Association of Directors of Medical Student Education in Psychiatry (ADMSEP).

The formulation and subsequent use of objectives for the MCP psychiatry clerkship illustrate their benefits for a departmental teaching program. In 1992, the director of medical student education (ACB) and assistant clerkship director (KVZ) perceived a need for such objectives for the reasons detailed earlier and to improve teaching and evaluation in the clerkship. Although students had previously rated their clinical experience highly, they had complained about the didactic portion of the curriculum and the validity of the final examination. No formal objectives were used. We wrote first drafts and distributed these to faculty who taught clerks. In a series of meetings, several drafts were discussed and revised.

Initially, the project engendered confusion and skepticism. Concerns included that the document might emphasize academic performance at the expense of clinically meaningful experience, favor accumulation of knowledge over attitude change and skill acquisition, or stifle serendipitous and self-directed learning. Some faculty were uncomfortable with formal expectations of students, and some doubted this diverse group could achieve consensus. As time passed, most participants were reassured that their opinions were taken seriously, that the group could agree much of the time, and that objectives could encompass important noncognitive factors (14).

This resolution led to a second phase, articulating the educational purposes of the clerkship. Three guiding principles for inclusion of objectives emerged. Most important was the question of what a future generalist must know to adequately diagnose, and treat or refer, psychiatric problems he or she will likely encounter in future practice. Addressing this issue required knowledge of psychiatric epidemiology, presentations of psychopathology in primary care settings, and the stated educational needs of generalists (15-18). Second was the desire to acquaint students with psychiatry's scientific foundation and role as a medical specialty. We thereby hoped to decrease prejudice against the field, its practitioners, and its patients. Finally, a certain configuration was imposed by our department's resources and interests. For example, objectives on sleep disorders were excluded because this subject is taught by other MCP departments. We debated the boundaries between the clerkship and other departmental offerings, and between psychiatry and other disciplines.

Many interesting and intense discussions ensued, occasionally requiring that subgroups work on sections of the document. We became more adept as we worked through several drafts, "losing" only one participant because of irreconcilable differences. As we proceeded, "minimalist" expectations were replaced by more idealistic ones.

We began using the objectives in July 1993. The students were told that the objectives were intended to guide their study, representing what we thought a medical school graduate ideally should know about psychiatry. They were not expected to master all objectives during the 6-week clerkship, and the students were encouraged to use whatever texts and other resources they chose to achieve their goals. The didactic portion of the clerkship and the final examination were keyed to the objectives.

Copies were also distributed to all faculty and residents. Faculty lecturers, almost all of whom had helped to formulate the objectives, understood that their lectures should respond to these stated expectations.

Although it was easier to incorporate the knowledge objectives into the clerkship curriculum, efforts were made to address the behavioral and attitudinal ones as well. For instance, the psychiatric interview course referred to the objectives for interviewing skills. An interview rating checklist based on these objectives was given to students and used by attending supervisors to evaluate a live or videotaped interview, which formed part of the final evaluation. In addition, students were taught and practiced skills in giving and receiving critiques of their interview technique. This exercise attempted to realize several objectives from the "Attitudes, Perspectives, and Personal Development" section on evaluating one's own performance, using and providing constructive criticism, and demonstrating respect and empathy for patients and colleagues. In these cases, the objectives reduced the perceived distance between the teaching of "process" and "content" by specifying both the content of the process and the behavioral application of the content.

Evaluation by the students of the objectives themselves has been largely positive; on average they are rated "good" (4 on a 5-point scale). Informal feedback suggests that they are very helpful to some students and not used much by others, consistent with the literature on student use (19). Unfortunately, sufficient comparable data regarding student rating of the overall clerkship experience before and after the objectives were used are not available. However, student evaluation of all junior clerkships from 11 "blocks" from November 1991 through June 1994, conducted by the Office of Medical Education, revealed that psychiatry was the highest ranked clinical clerkship, receiving the highest scores in 6 of 7 items. Two items directly related to the objectives: "objectives, expectations, and evaluation procedures for my performance were provided" and "the clerkship gave me an adequate base of knowledge and skills in this discipline." The well-organized teaching program was consistently cited in the students' comments.

Studies of objectives in medical education suggest that faculty input into, and use of, objectives is related both to improvements in teaching and to student use of them (20,21). Semistructured interviews regarding the effect of the process and their subsequent use were conducted with 10 MCP faculty in the spring of 1994. The interviewees ranged widely in academic rank and included two who had not worked on the objectives. Over 80% of the clerkship lecturers and attending physicians and all service divisions were represented in the sample.

Several themes emerged repeatedly. First was the unanimous perception that the project was worth the effort, produced a valuable teaching aid, and benefited the participants personally. All faculty interviewed used the objectives, adapting them to fit their own circumstances, values, and styles. All used them in preparing lectures, but other uses were reported as well, such as reading sections to reinforce clinical teaching, or using them while reviewing students' written histories. Some stated they used objectives they particularly liked or that fit the style or setting of their instruction. Benefits to teaching that were mentioned included increased focus, more appropriate level of instruction, and greater reinforcement of targeted material. Several reported more confidence in their teaching; one person commented that, whereas students frequently had walked out on his prior lectures, they now appeared interested because he was teaching "the right stuff." Faculty seemed to take their teaching role more seriously because they felt responsible for a part of the curriculum they had helped to formulate. Several wanted to make changes and additions to respond to student needs.

In general, a faculty member's level of participation in writing the objectives predicted his or her subsequent use of them. Some primarily used sections they had helped to develop and seemed to feel "ownership" of these. Several commented on how important it was that the objectives were not externally imposed, and some stated that having participated in the process made them easier to remember. The two subjects who used the objectives the least had not participated in drafting them. One of these reported being taken to task by students for initially failing to use them for her lecture.

Benefits to the administration of the clerkship included increased focus in teaching and assessment, greater confidence and authority because of group accountability and collegiality, and more efficiency in communicating teaching goals. In some cases, the benefit of formulating and using objectives seemed to generalize to other aspects of teaching. One participant stated, "the process made me think about working in groups for educational administration." He subsequently started an educational steering committee at his hospital and used a similar process to formulate objectives for the hospital's residency. Many interviewees commented that, with increased familiarity with writing and using the objectives, they found them useful in other courses. One subject prepared and used the objectives in studying for her psychiatry boards.

Having been a part of this process made some faculty, particularly younger and geographically dispersed members, feel more a part of the department, and several people commented on their increased sense of shared mission. On the other hand, one interviewee "felt I was in the minority," and another "wished I had pushed my point of view harder."

All interviewees saw a need to update the objectives periodically. Organic metaphors abounded: one teacher commented, "the objectives are sort of living things to me," and another said "they need to be revised every year, like a garden." It would appear that, for faculty, the process was as important as the product.

Finally, concern that these detailed objectives would intimidate faculty and students has waned. With practice, people learned to use them to their advantage. Only one faculty member felt they were too detailed and suggested they be prioritized. Two felt that more emphasis should be placed on attitudinal and behavioral objectives. However, several were pleased that the objectives were detailed: "it is especially important in psychiatry because of the perception that we aren't real doctors and we don't have a lot to teach" and "it's worthwhile to have a higher goal than can be achieved." Several commented that the objectives probably would not be used much by students unless their use was reinforced by faculty, a conclusion that has been reached by others (20).

In 1993, Dr. Sierles, then president of ADMSEP requested copies of the objectives that were being used by members in their junior psychiatry clerkships. The objectives that had been developed at MCP were felt to sufficiently encompass those submitted by medical student educators from the 45 responding schools to serve as a first draft of a comprehensive ADMSEP-sponsored document. These were revised and edited by the three authors, and topics and objectives were added from other departments' submissions.

Subsequently, these objectives were presented to, and deliberated by, attendees of ADMSEP's annual meeting in June 1994. Key issues included whether such a document was needed, whether the objectives should reflect bare bones essentials or a high standard of knowledge and skill, and whether they should encompass a 4-year psychiatry and behavioral science curriculum or be confined to the clerkship. In addition, Dr. Michael Weissberg presented the University of Colorado medical student log (22), which described 10 core supervised experiences required of their clerks (e.g., "assessing a patient for suicide or homicide risk"). The complementarity of the detailed MCP/ADMSEP objectives and Colorado's "experiential" log was noted. A committee for psychiatry clerkship objectives was appointed.

Copies of the objectives and log were then sent to all ADMSEP members along with a questionnaire soliciting impressions of the project and suggestions for revision. Overall, the membership supported the undertaking. Many suggested changes were considered and included.

The committee had concerns similar to those faced at MCP. First, the relatively high level of knowledge and skill expected might be too idealistic, even quixotic. We concluded that the level of detail was no greater than that of the surgical, gynecologic, and pediatric objectives and that diluting them would reinforce the idea that psychiatry had little substance. In addition, each objective was felt to be clinically important, attainable, covered in standard texts, and testable. The decision to abjure a minimalist standard was based on the demonstrated need for more sophisticated psychiatric practice in primary care settings. Finally, it was felt that these objectives should be viewed in the context of a 4-year curriculum in psychiatry and behavioral science. Some objectives might be addressed in preclinical courses (e.g., behavioral science, introduction to clinical medicine, neuroscience, and psychopathology) and in other clerkships. There is no expectation that any student will master them during a clerkship. They were meant to guide learning, representing what, ideally, a medical school graduate should know about psychiatry.

We also discussed whether these objectives should represent a formal national clerkship curriculum. Although produced and endorsed by ADMSEP, we expected that each school would use or not use them based on its unique history, philosophy, and resources. Because formulating and editing such a document de novo requires so much time and effort, we thought many departments might use them as a starting point for discussion and consensus development regarding their school's clerkship. Although these objectives were intended only as a guide, we were struck by the remarkable degree of agreement on psychiatry clerkship objectives among the different schools.

A final consideration pertained to the educational advantages and potential pitfalls of objectives. One ADMSEP member was concerned about the potential for teacher-generated objectives to restrict learning and discourage creative risk-taking by constraining self-directed education and implying that objectives are a ceiling for learning. Objectives are not individualized to the student's unique aptitudes and interests, and "universal" objectives do not account for departmental differences. Clinical experience is opportunistic and cannot be rigorously controlled (23). However, the literature on objectives suggests that many pitfalls can be avoided with correct construction and appropriate use (19-21, 24,25). In fact, even problem-based learning programs, which focus on student-centered learning, widely use objectives in preparing clinical cases. Objectives should be written at the appropriate level of difficulty for students using them, neither too easy nor discouragingly unattainable. As well, they should avoid the extremes of overgeneralization and vagueness on one hand, excessive detail and inclusiveness on the other (26,27). Care must be taken to formulate some objectives requiring more complex levels of thought, attitude, and behavior ("higher order objectives") to deemphasize the memorization of facts (28). We attempted to follow these guidelines in writing and editing the ADMSEP objectives, which are shown in the Appendix.

Our experience formulating and using learning objectives in the psychiatry clerkship at MCP illustrates the positive effects of this process on the learning environment, particularly on the faculty. Much of the benefit appears to be derived from the process of articulating the objectives, implying the need for continued active use and revision. We hope that the ADMSEP objectives will serve as a starting point for similar reviews at other schools.

The authors thank Cindy Sinvani for her assistance in manuscript preparation.
Portions of this paper were presented at the 1994 Association of Directors of Medical Student Education in Psychiatry annual meeting in Tucson, Arizona, and at the 1995 annual meeting of the American Psychiatric Association in Miami Beach, Florida.