COMMENTARY

Diminishing Number of Clerkship Sites Poses Threat to Psychiatry Training

Jacqueline Posada, MD, and Patricia E. Ortiz, MD

October 11, 2021

Medical school clinical rotations are a rite of passage as students emerge from their basic science courses and first board exam to the clinical world where the patients vaguely resemble the question stem descriptions. Finally, intangible theory can be put into practice. Yet, it is becoming increasingly difficult for 3rd-year medical student clerkship directors to find enough clinical sites to support the growing number of medical students as enrollment numbers steadily increase and outpace the current clinical resources.

In a 2019 Association of American Medical Colleges report, 84% of medical school deans were concerned about the diminishing number of clerkship sites, and there was additional worry about lack of qualified specialty preceptors. This lack of clerkship availability is especially true for psychiatry sites.

Psychiatry clerkship directors are in need of more clinical sites to address the educational needs of medical students, and psychiatrists in the broader clinical community are positioned to help medical schools expand their clinical sites.

Inpatient psychiatric units and consult services continue to be popular sites for medical student rotations, but it has been hard to expand into other settings, where psychiatric treatment is seen as more private and intimate than other specialties. Reasons for falling site availability are varied and include 1) financial disincentive to take students – because they can be seen as a burden on supervisors who must meet revenue-generating patient quotas; 2) competition with other learners, including residents, PA students, NPs, and NP students; and 3) the general financial and operational obstacles to clinical practice inflicted by the pandemic. COVID-19 affected medical education – for better and worse (JAMA. 2020;324[11]:1033-4). Psychiatry clerkships particularly suffered from restricted patient access as inpatient units reduced their census to comply with COVID-19 safety protocols, and during the height of the pandemic inpatient units provided psychiatric care to COVID-19–positive patients, which precluded student involvement. On the other hand, many more students were introduced to telepsychiatry and witnessed creative forms of mental health intervention as clinicians adapted their practices to the pandemic.

When Rotations Began

Clinical rotations entered the American medical school curriculum in the 1890s when Sir William Osler brought the European standard of medical education with him as Physician in Chief at the newly opened Johns Hopkins University Hospital. He formalized the traditional apprenticeship model by standardizing 3rd- and 4th-year clerkships as rotations in which medical students worked in clinics and on the wards, learning from residents and attendings.

Clinical rotations, their location, the supervisors, and the patients and their ailments all go in to influence a student's specialty choice. Some students enter medical school knowing they want to be a surgeon, a pediatrician, or a psychiatrist. And some are compelled by a specific rotation, when they realize that it's not at all what they expected and maybe they could dedicate their professional life to this area of medicine.

High-quality clinical clerkship sites are essential to the future of psychiatry. At clerkship sites, undecided students interested in psychiatry may affirm their commitment to psychiatry. Other students will have their only dedicated exposure to psychiatrically ill patients. This represents students' only opportunity to learn the skills to treat comorbid psychiatric and medical illness. Regardless of specialty, nearly every physician will have to treat patients with some psychiatric illnesses.

What constitutes a "high-quality clinical site" is difficult to measure and define. Some measures of quality include a safe learning environment, a reasonable ratio of students to supervisors (including residents, fellows, and attendings), and an adequate number and diversity of patients. Many medical schools may prefer an affiliated academic medical center or Veterans' Affairs hospitals for their rotating students. Private psychiatric hospitals are proliferating, and if these are to be sites for medical students, the following standards are suggested: Private psychiatric hospitals must follow standard safety precautions with sufficient staff presence, ensure willing preceptors who can provide adequate student supervision, and adjust their expectations to students who can carry a few patients of diverse background, but are not to be treated merely as scribes.

Psychiatrists, whether they consider themselves "academic" or not, have a role to play in expanding access to clinical sites. Students are eager to learn in any setting. Inpatient settings have long been seen as the norm for clinical education in psychiatry. Yet inpatient settings perpetuate the idea that those with severe mental illness or individuals with psychosocial stressors or disabling, comorbid substance use disorders are the only people who seek help from a psychiatrist. This article is a call to action to our colleagues in community mental health centers, managed care settings, and other psychiatric treatment providers without an academic affiliation to explore the possibility of creating space for a medical student in their clinical practice.

We cannot deny the demands on psychiatrists' time – every minute is counted by the patient and doctor, and every encounter is accounted for in some revenue stream. However, the academic world is running out of space for its students, and there's a serious question as to whether an academic center is the only place for students. If you are a psychiatrist who still loves to learn and prides themselves on high-quality patient care, then you have an essential role in shaping the students who will one day be your peers in psychiatry, or the physicians treating your patients' comorbid medical illnesses.

There are upfront challenges to teaching 3rd-year medical students, including teaching the psychiatric interview, note writing, persuading patients to allow students into their care, and setting time aside at the end of the workday to provide feedback on performance. Yet, after learning the ropes of psychiatric patient care, medical students can provide help in writing notes, calling collateral, contacting patients with their laboratory results, and even helping with the tedious but necessary administrative tasks like prior authorizations. In exchange for training students, some medical schools may offer perks, such as a volunteer faculty position that comes with access to usually expensive library resources, such as medical databases.

You can help expand clinical sites in psychiatry rotations by contacting your alma mater or the medical school closest to your community and asking about their need for clerkship sites. Many medical schools are branching out by sending students to stay near the clinical sites and immerse themselves in the community where their site director practices. Even one-half day a week in an outpatient setting provides patient and setting diversity to students and helps spread out students to different sites, easing the burden on inpatient supervisors while providing students more individualized supervision.

The practice of medicine is built on apprenticeship and teaching wisdom through patient care. Just because we leave residency doesn't mean we leave academics. Taking students into your practice is an invaluable service to the medical education community and future physicians.

Posada is assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University in Washington, and staff physician at George Washington Medical Faculty Associates, also in Washington. She has no conflicts of interest. Ortiz is assistant professor and clerkship director in the department of psychiatry at Texas Tech University Health Sciences Center – El Paso. She has no conflicts of interest.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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