Revised Position Paper
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.
.
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.
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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
|
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.
|
|
|
|