Psychiatry clerkship directors: Who they are, what they do, and what they think

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<ul><li><p>PSYCHIATRY CLERKSHIP DIRECTORS: WHO THEY ARE, WHAT THEY DO, AND WHAT </p><p>THEY THINK </p><p>Freder ick S. Sierles, M.D., and Diane Magrane, M.D. </p><p>We mailed questionnaires to ascertain biographic, academic and attitudinal data about psychiatry clerkship directors in the U.S. The average director is 46 years old, has been in academic medicine for 13 years, and has directed the clerkship for 5.9 years. Most are associate or full professors and hold one or more additional administrative positions, most often director of medical student education in psychiatry. Most view their role as fulfilling and want to direct the clerkship for the rest of their careers. However, most also perceive that their medical school does not provide enough support, that faculty don't teach enough, and that the current economic climate impedes learning. Unless medi- cal student education is supported under managed care, the quality of clerk- ships and job satisfaction for clerkship directors will decline. </p><p>For most Amer ican physicians, the psychiatry clerkship is the only comprehens ive educat iona l exper ience in psychiatry. As many nonpsychiatr ic physic ians examine and refer or t reat psy- chiatr ical ly ill persons, a good psychiatr ic clerkship is essential . </p><p>Frederick S. Sierles, M.D., is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences/The Chicago Medical School. Diane Magrane, M.D., is Associate Professor of Obstetrics and Gynecology and Associate Dean for Curriculum, University of Vermont College of Medicine. </p><p>Address correspondence to Frederick S. Sierles, M.D., Finch University of Health Sciences/The Chicago Medical School, 3333 Green Bay Road, North Chicago, IL 60064. </p><p>PSYCHIATRIC QUARTERLY, VoI. 67, No. 2, Summer 1996 0033-272{Y96/0600-0153509.50/0 9 1996 Human Sciences Press, Inc. 153 </p></li><li><p>154 PSYCHIATRIC QUARTERLY </p><p>Like clerkship directors in other specialties, the psychiatry clerk- ship director plans the clerkship and ensures that the plan is implemented, by orienting the faculty and students, monitoring the clerkship, teaching in the clinical setting and classroom, pre- paring or selecting the clerkship examination, coordinating the grading of students, evaluating the clerkship, and responding to student and administrative problems (1). Also, many researchers of medical student career choice of psychiatry assert that, for recruitment, the psychiatry clerkship is the most important medi- cal school experience (2). </p><p>In 1990, Herbert, Cummings and Droegemueller (3) reported about clerkship directors in obstetrics and gynecology, indicating that the majority were senior level faculty with considerable ex- perience in the directorship. In 1994, Johnson and Michener (4) reported about family medicine clerkship directors, the vast ma- jority of whom experience considerable job satisfaction. To our knowledge, no systematic biographic and attitudinal data have been published about clerkship directors in any other specialty, including psychiatry. Given the importance of clerkships, this paucity of data is puzzling. As part of a national clerkship di- rectors' survey of the multi-specialty Alliance for Clinical Educa- tion, we conducted this study to ascertain demographic and academic characteristics and attitudes and aspirations of psychia- try clerkship directors. </p><p>STUDY DESIGN AND PROCEDURES </p><p>We mailed a 60-item questionnaire requesting information about demographic characteristics, academic careers, attitudes and as- pirations of psychiatry clerkship directors at 126 U.S and two Canadian medical schools. We also asked them about their clerk- ship and their department's administrative structure. Attitudes were identified by asking directors whether they agreed with each of 16 statements, such as "Being a clerkship director is per- sonally fulfilling." Respondents were assured anonymity; they were told that the questionnaire and return envelope had no identifying marks, and were asked to omit identifying details. There were two mailings, in May and July of 1994. The first </p></li><li><p>FREDERICK S. SIERLES AND DIANE MAGRANE 155 </p><p>mailing was to members of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), the majority of whom are clerkship directors. Two ADMSEP members are Cana- dian. We did not determine whether either Canadian replied. The second mailing was to ADMSEP members and to chairpersons of departments with no ADMSEP representatives. If the recipient of the questionnaire was not the clerkship director, he or she was asked to give the questionnaire to the director. </p><p>FINDINGS </p><p>Of the 128 medical schools (126 American, 2 Canadian) to which questionnaires were sent, we received responses from the psy- chiatry clerkship director at 107 (83.6% of) schools. Table 1 sum- marizes demographic and academic data about the directors. The average psychiatry director is 46 years old and has directed his or her clerkship for 5.9 years. This average tenure in the direc- torship of current directors exceeds the average total tenure of the directors' predecessors. Thirty per cent, however, have been directors for two years or less. </p><p>Ninety four percent of respondent directors are psychiatrists; all responding psychiatrists are board certified, and some also have subspecialty qualifications. The majority of psychiatry di- rectors are professors or associate professors. Their academic ranks do not significantly differ (chi squared = 6.01, df = 3, P = &lt; 0.1, NS) from those of psychiatry residency directors. Among the 107 clerkship directors, 5 (5.6%) are instructors, 38 (35.5%) assistant professors, 34 (31.8%) associate professors, and 29 (27.1%) professors. Of the 94 residency directors whose aca- demic ranks were listed by the respondents, one (1.06%) is an instructor, 25 (26.6%) are assistant professors, 33 (35.1%) asso- ciate professors, and 35 (37.2%) professors. </p><p>Ninety one percent of clerkship directors hold one or more ad- ditional administrative positions, the most common being director or co-director of medical student education in psychiatry, psycho- pathology course coordinator, behavioral science course coordina- tor, and clinical service director (Table 2). </p></li><li><p>156 PSYCHIATRIC QUARTERLY </p><p>TABLE 1 </p><p>Demographic and Academic Characteristics of Psychiatry Clerkship Directors (N - 107) </p><p>Mean S.D. Range </p><p>AGE (years) 46.1 9.4 30-71 YEARS AS A FACULTY MEMBER </p><p>in current department 10.6 8.2 0.5-40 in career 13.0 8.9 0.5-40 </p><p>YEARS AS A CLERKSHIP DIRECTOR 5.9 5.3 0.2-25 </p><p>Years as a clerkship director of the current director's predecessor (N = 79) 5.8 5.0 </p><p>Number Percent </p><p>SEX Female 26 24.3 Male 81 75.7 </p><p>DEGREE MD and PhD 2 1.9 MD 98 92.4 PhD 4 3.8 EdD 2 1.9 </p><p>TENURED Yes 35 33.0 No 71 67.0 </p><p>BOARD CERTIFIED Yes, with subspecialization 17 16.3 Yes 77 74.0 No 7 6.7 Other 3 2.9 </p><p>MEMBER OF DEPARTMENT'S EXECUTIVE COMMITTEE </p><p>Yes 49 45.8 No 43 40.2 No committee 15 14.0 </p><p>0.2-25 </p></li><li><p>FREDERICK S. SIERLES AND DIANE MAGRANE 157 </p><p>TABLE 2 </p><p>Additional Administrative Roles Held by Psychiatry Clerkship Directors </p><p>Number Percent (1) </p><p>Director or co-director of medical student education in psychiatry </p><p>Psychopathology course director Behavioral science course director Clinical service chief Residency director or assistant </p><p>director Department education director Vice chairperson Assistant or associate dean </p><p>71 66.4 29 27.1 27 25.2 25 23.4 </p><p>8 7.5 7 6.5 5 4.5 2 1.8 </p><p>(1) N &gt; 100% because most directors have multiple roles. </p><p>In response to our question "How many hours do you work in average week?" the mean of psychiatry clerkship directors' re- sponses was 51.7 hours (S.D. = 9.4). Directors report spending an average of 14.6 hours weekly (S.D. = 8.9) caring for patients with no trainees present, 13.6 hours teaching (S.D. = 8.5), 11.2 hours in educational administrative duties (S.D. = 8.6), and 5.9 hours conducting research (S.D. = 8.7), Of the 13.5 hours spent teaching weekly, 5.5 hours (S.D. = 5.7) is devoted to bedside and clinic teaching of students, 4.1 hours (S.D. = 3.4) to teaching stu- dents in the classroom, and 3.9 hours (S.D. = 4.3) to teaching residents with no students present. All but one of the clerkship directors has a clinical practice. </p><p>Psychiatry clerkship directors' attitudes are summarized in Table 3. The majority of directors find the director's role to be personally fulfilling. Most directors feel that good teaching en- hances a faculty member's reputation and that teaching should weigh as heavily as research in earning promotion and tenure. Most directors think that having the role of clerkship director does not impede career development. </p></li><li><p>158 PSYCHIATRIC QUARTERLY </p><p>TABLE 3 </p><p>Attitudes Held by Psychiatry Clerkship Directors </p><p>Percent agreeing with statement </p><p>(N = 107) </p><p>1. Being a clerkship director is personally fulfilling. </p><p>2. Good teaching makes a major contribu- tion to the reputation of faculty. </p><p>3. Teaching should have less weight in pro- motion/tenure decisions than research/ publications. </p><p>4. Faculty should be promoted on the basis of teaching even if publications are low. </p><p>5. Faculty view teaching as a respected academic activity. </p><p>6. The role of a clerkship director tends to hamper career development. </p><p>7. To teach students and residents effec- tively, clinical teachers should engage in clinical practice. </p><p>8. The present economic situation has a negative effect on how students are taught. </p><p>9. My medical school gives me the support I need to conduct my activities effec- tively. </p><p>10. Faculty spend too little time teaching. 11. Performing research enhances a faculty </p><p>member's teaching. 12. The activities of a clerkship director </p><p>enhance academic promotion. 13. Faculty must be careful not to allow </p><p>teaching to interfere with research activities. </p><p>80.4 </p><p>62.6 </p><p>8.4 </p><p>77.6 </p><p>51.4 </p><p>25.2 </p><p>86.0 </p><p>68.2 </p><p>48.6 57.9 </p><p>34.6 </p><p>30.8 </p><p>5.6 </p></li><li><p>FREDERICK S. SIERLES AND DIANE MAGRANE 159 </p><p>TABLE 3 (Continued) </p><p>Percent agreeing with statement </p><p>(N = 107) </p><p>14. It is no longer possible to excel in teaching, research and clinical practice simultaneously. </p><p>15. Good teaching gains a faculty member as much peer respect as does producing research and publication. </p><p>16. Faculty should have extensive formal training in teaching. </p><p>57.0 </p><p>24.3 </p><p>36.4 </p><p>Although most clerkship directors find their role fulfilling, most also feel that the national economic climate negatively affects how students are taught, that their school does not support them sufficiently, and that their department's faculty does not teach enough. </p><p>Table 4 summarizes responses to the request "Your ultimate career goal/aspiration is (check as many as app ly ) . . . " Seventy (65.4% of) clerkship directors want to remain in their current roles. Of the 78 directors who were not professors, 36 (46.2%) aspire to a professorship. Fourteen percent wish to become an associate dean or dean. Spontaneous responses to the openended choice "other goal/aspiration (specify)" included "research" for 6.5%, and "retirement" for 3.7%. The mean age of the four sub- jects writing "retirement" was 58.8 years. </p><p>Table 5 summarizes data about psychiatry clerkships. At all 107 schools, a psychiatry clerkship is required. Between academic years 1993-94 and 1994-95, the psychiatry clerkship length re- mained the same in 97.2% of the schools. Nationally, psychiatry clerkship lengths range from 4-9 weeks, with six and eight weeks by far the most frequent lengths. The overwhelming majority of directors reported that their clerkship emphasized inpatient over ambulatory care. </p></li><li><p>160 PSYCHIATRIC QUARTERLY </p><p>TABLE 4 </p><p>Career Aspirations of Psychiatry Clerkship Directors (N = 107) </p><p>Number Percent (1) </p><p>To remain in my current roles To become a professor (2) Associate dean/dean Residency director Primarily private practice Primarily salaried practice Retire/semi-retire Vice chairperson Business executive </p><p>70 65 36 42 15 14 9 8.4 9 8.4 7 6.5 4 3.7 2 1.87 2 1.87 </p><p>(1) N &gt; 100% because some directors have mult iple career goals. (2) 29 are a l ready professors. </p><p>TABLE 5 </p><p>Characteristics of U.S. Psychiatry Clerkships (N = 104) </p><p>Length in Weeks in 1994-95 Number Percent </p><p>4 10 9.6 4.5 1 0.9 5 3 2.9 5.5 2 1.9 6 57 54.8 7 4 3.8 7.5 1 0.9 8 25 24.0 9 1 0.9 </p><p>Location of Student Assignments Number Percent </p><p>Primarily inpatient More inpatient than ambulatory Evenly balanced More ambulatory than inpatient </p><p>39 37.1 50 47.6 13 12.4 2 1.9 </p></li><li><p>FREDERICK S. SIERLES AND DIANE MAGRANE 161 </p><p>DISCUSSION </p><p>The high response rate suggests that the respondent sample ac- curately represents the population of psychiatry clerkship direc- tors. The data strongly suggest that most psychiatry clerkship directors are well suited for their role. Mature in years, they are experienced medical student educators who enjoy their work and aspire to be directors for the rest of their careers. On average, they have already worked as directors longer than did their predecessors. They value teaching highly. They practice clinically and correctly perceive that clinical practice makes them better teachers. Most are well rewarded in terms of academic rank and tenure. Between 1993-94 and 1994-95, psychiatry clerkship lengths remained the same in virtually all schools, suggesting that the movement towards primary care education has not changed the perception that a solid psychiatry clerkship is es- sential for generalist practitioners. </p><p>The survey also reveals three problems. First, because medical practice is shifting progressively more to ambulatory care, the Association of American Medical Colleges and medical school ad- ministrations urge more student assignments to ambulatory care settings. However, the vast majority of psychiatry clerks are as- signed to inpatient units. That all but one of the clerkship di- rectors spend considerable time treating patients with no trainees present suggests, but does not prove, that many faculty primarily treat outpatients in university private practices while assigning trainees to participate in inpatient care. Future studies should ascertain whether there is a faculty outpatient-trainee inpatient dichotomy, and efforts should be made to integrate more psy- chiatry clerks into the outpatient setting. </p><p>The second problem is that most psychiatry directors perceive that conducting research is not essential to their teaching. But engaging in research forces faculty to view critically what they teach, and to convey this tough-mindedness to their students. </p><p>The third problem is that, despite enjoying their work, many psychiatry directors feel inadequately supported by their school and think that the national economic situation affects their teach- ing negatively. Many directors believe that faculty do not teach enough. Unless medical student education is supported under </p></li><li><p>162 PSYCHIATRIC QUARTERLY </p><p>managed care, and unless this support translates into medical school support of clinical training and protected time for teaching by clinical faculty, the quality of psychiatry clerkships m all clerkships for th...</p></li></ul>