REVIEW ARTICLE A Consultation-Liaison Psychiatry Clinical Clerkship F. PATRICK MCKEGNEY, MD,* AND SHELDON WEINER, MDt Toward the goal of increasing the relevance of clinical psychiatry to the future practice of medicine, a full-time psychiatry clerkship has been developed on the Consultation—Liaison Psychiatry Service at the University of Vermont. This new Psychiatry Clinical clerkship was begun on a pilot basis in January, 1973, and made fully operational in January, 1974. It uses the problem oriented medical record system and the audit of student performance as basic instructional tools. A description of the background or curricular matrix of this Consultation-Liaison Psychiatry Clinical Clerkship (CLPCC) is followed by an outline of the rotation's goals, ahd evaluation and educational strategies as developed over 2 years. Certain performance outcomes are reported for the 1 year of full operation. These outcomes are parameters of student performance on several standardized measures applied to all Psychiatry Clerkship students. The CLPCC students seem to be at least as adequate as students on all other clerkship rotations, in terms of their knowledge of psychopharmacology, theiruse of the Problem Oriented Record, their ability to assess psychosocial problems, and their ability to define a psychosocial treatment plan. Further, the CLPCC students are statistically significantly more positive about their rotation as an educational experience compared with students on other psychiatry rotations. While further evaluation measures are planned to compare th e CLPCC students with those who have had one of the several traditional clinical clerkship experiences in psychiatry, our experience to date would indicate that the CLPCC is a viable alternative to traditional clerkships on psychiatric services and one that may enable a greater application of psychiatric principles to the practice of medicine.
THE PROBLEM Medical curriculum changes over the past decade have been extensive, particularly toward less basic science time, increased elective time, earlier specialization or "tracking," and overall compression of college, medical school, and post-M.D. training. The "internship" year
From the Department of Psychiatry, College of Medicine, University of Vermont, Burlington, Vermont 05401. "Professor of Psychiatry and Director, Consultation-Liaison Service. tProfessor and Chairman of Psychiatry, former Director, Consultation-Liaison Service. This paper was originally presented at the University of Rochester, Department of Psychiatry, Grand Rounds, February 6,1975. Work supported in part by NIMH Training Grant #2 T01 MH08052-12. Received for publication March 10,1975, revision received June 16, 1975.
as most of us have known it is being challenged. Only the traditional required clinical clerkships in the "basic" disciplines, Internal Medicine, Surgery, ObstetricsGynecology, Pediatrics, and Psychiatry, have remained relatively intact in this recent convulsion of change. To be sure, some modifications have been made in this pivotal period in the medical students' evolution into physicians. The total time devoted to these required clerkships has been somewhat decreased, and family practice or primary care clerkships have been added in some schools. However, the required clerkships generally remain unchanged, occupying a year or more in the middle of medical school, taught by research-oriented medical specialists or by interns, residents, and fellows who aspire to a similar career of "superspecialization." These clinical clerkships are usually
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976) Copyright s 1976 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
45
F. PATRICK MCKEGNEY AND SHELDON WEINER
spent on specialty inpatient services, caring for a patient population highly selected for diseases in that specialty. Only occasionally are physicians from other disciplines involved in teaching the student on the specialty-bound clerkship. Immersed in the inpatient practice of a given specialty, students rarely can extract the principles of that specialty field that are pertinent to the other fields of medicine. An absence of relevance for most future physicians is a serious deficiency in any specialty clinical clerkship. It is most regrettable in the Psychiatry Clerkship, which may be the first, and last, opportunity for the student to be intensively involved with the patient in an interpersonal-social-environmental context. However, required Psychiatry clerkships primarily expose the student to the diagnosis and treatment of "psychiatric" patients by skilled mental health professionals in a psychiatric setting. Such Psychiatry clerkships, as a result, usually fail in enabling the student to acquire the knowledge, skills, and attitudes for the observation and assessment of human behavior and appropriate personal intervention in the practice of medicine. A temporary digression into the area of state-dependent learning may further emphasize this point. This theory simply states that information learned in one state is best recalled in that same state, and is exemplified by recent studies with alcohol and chronic alcoholics. Many chronic alcoholics claim that the location of money or alcohol, which had been hidden in the course of a drinking bout for safekeeping, could not be remembered during the subequent sobriety; recall only occurred during the next immediate drinking episode. This phenomenon was experimentally confirmed by Goodwin (1) in a controlled 46
study that utilized pornographic pictures as the learned stimulus and sobriety and intoxication as the variable states. If one cannot recall pornographic pictures, should one realistically be expected to recall psychiatric principles? Thus, it can be reasoned that, if most medical students learn psychiatry in psychiatric settings, but ultimately practice in different settings, then recall of psychiatric principles will be compromised. Our prior experiences with medical students on nonpsychiatric services would seem to validate this hypothesis; the learning that they had acquired during their Psychiatric Clerkship had somehow dissipated when they moved to other clinical rotations. In summary, as in other required clinical specialty clerkships, the teaching of psychiatry has traditionally taken place on psychiatric services, with "psychiatric" patients, and has emphasized nosology, psychopathology, psychodynamics, and psychotherapy by skilled mental health professionals. As a result, the relevance and "carryover learning" of psychiatric principles as applicable to nonpsychiatric patients by future nonpsychiatrists is compromised. In an effort to improve such relevance and carryover learning, a new psychiatry clinical clerkship was begun on a pilot basis in January, 1973, and made fully operational in January, 1974. It is based on the Department of Psychiatry Consultation-Liaison Service and uses the problem oriented medical record system and audit of student performance as basic instructional tools. A description of the background or curricular matrix of this Consultation-Liaison Psychiatry Clinical Clerkship (CLPCC) will be followed by an outline of the goals, and evaluation and educational strategies as developed over 2 years. Certain student performance out-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
comes are reported for the 1 year of full operation. The University of Vermont Medical School has a 4-year program leading to the M.D. degree. Medical students have their 8-week Psychiatry Clerkship sometime during the 48-week Clinical Core, which begins in January of their second year. Prior to the Clinical Core, the students have considerable exposure to the principles of psychological medicine: in the first year a Human Behavior course (50 hr); in the second year in Human Sexuality (24 hr) and Psychopathology (26 hr) courses; and in the Basic Clerkship, or introduction to clinical medicine, in which psychiatrists take an active part, throughout the first year and a half of medical school. After the Clinical Core, students spend the last 15 months in the Senior Major Program, taking a wide range of electives, which are predominantly clinically related, selected according to their projected future careers. Students beginning the Psychiatry Clerkship spend their first day in a general orientation, which includes an introduction to the five clinical services to which they can be possibly assigned (on the basis of student quotas): an acute 32-bed, general hospital inpatient psychiatric unit (4); the emergency room-crisis clinic (2); a short term ambulatory psychiatric clinic (3); a regionalized unit of the Vermont State Hospital (2); and the C-L Service (4). Final assignments are made according to student preference, within the constraints of the service quotas, with most students receiving their first choice and the remainder usually assigned to their second choice.
culty consists of the equivalent of one and one half full-time psychiatrists and a quarter-time psychiatric nurse. The Director devotes somewhat more than half his time to the Service and five other psychiatrists teach students and residents 2-3 hr per week, on attending rounds or in the Primary Care Clinic. Two third year residents have full-time, 6-month assignments to the C-L Service and function as team leaders, being responsible for the day-today management of patients and the audit of student performance. Faculty members lead the daily attending rounds and are teachers and supervisors rather than direct providers of patient care. Student participation consists of two to four Clinical Core students who spend their 8-week clinical clerkship in psychiatry with the C-L Service, and Senior Major students who may have elected 1- or 2-month rotations. Interns and residents from other disciplines may also spend elective time on this service. Senior nursing students spend 8-12 weeks part-time on the service. The Consultation-Liaison Service attends to all psychiatric problems in the 500-bed Medical Center Hospital of Vermont, excluding the emergency room and the 32-bed inpatient unit. Approximately 500 consultations are seen annually. In addition to performing consultations, psychiatrist and nurse faculty and residents participate in staff-focused liaison activities in various medical and surgical specialties, according to principles described elsewhere (2).
GOALS
The University of Vermont College of Medicine has always emphasized the clinical practice of medicine in its educational BACKGROUND programs. The great majority of current The Consultation-Liaison Service fa- students express such an interest, with ap-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
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F. PATRICK MCKEGNEY AND SHELDON WEINER
proximately half being most interested in family practice. All students on the Psychiatry Clerkship are expected to meet eight overall objectives with specified behavioral outcomes (available on request). Within this institutional and student interest context, the Consultation-Liaison Psychiatry Clinical Clerkship (CLPCC) is designed to enable the student to acquire the knowledge, skills, and attitudes of the field of psychiatry that are most relevant to the practice of medicine in fields other than the specialty of psychiatry, particularly in the field of primary care or family practice. The particular goals of the CLPCC are to enable the student:
9. To accept peer audit and to develop techniques of self-audit, toward meaningful continuing education in the practice of medicine. METHODS—EVALUATION STRATEGIES
The basic evaluation strategies of the CLPCC involve (a) individual and group supervision of a student's performance in working with patients and in discussions with peers and supervisors and (b) audit of the student's written performance using the problem oriented medical record (POMR). This supervision and audit are largely carried out by the residents and faculty of the C-L Service, although an increasing emphasis is being placed on faculty supervision of a student peer audit process. It is hoped that this latter technique will enhance the development of selfevaluative skills for ongoing continuing education, and a positive attitude toward peer review processes in the future practice of medicine. Thus, the day-to-day student evaluation and education is carried out by frequent, immediate, and personal feedback to the students about their performance in the process of clinical work relevant to both patient and student and in the context of clear objectives and criteria for performance. In addition, the C-L Service Director provides evaluative feedback pooled from the residents and other faculty in a weekly group meeting of all CLPCC students and in a twice-perrotation individual meeting with each student.
1. To gather a reliable and comprehensive psychosocial data base, both subjective (historical) and objective (mental status); 2. To define a psychosocial problem list and relate these problems to the patient's overall health /disease status; 3. To assess a patient's problems in terms of clinical, dynamic, psychogenetic, and biological formulations; 4. To develop treatment plans for the patient's problems that are practical and could feasibly be carried out by the primary care physician; 5. To develop interpersonal skills with a wide range of patients in order to meet the above goals most effectively; 6. To develop basic psychotherapeutic skills with patients and families appropriate for the primary care physician; 7. To be able to use psychopharmacologic interventions in a wide range of Near the end of each rotation all stuproblems; dents participate in a standardized evalua8. To be able to carry out an effective tion process that has two components: referral of patients to other resources appropriate to the treatment plan, including 1. A formal half-day session in which referral to a psychiatrist; students: 48
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
opinions about the quality of (a) Do problem oriented data bases and assessments of one written their educational experience on case history and four videotaped their rotational service and qualpatient interviews. ity of their individual supervisors. (b) Complete a 25-item National Board-type psychopharmacol(c) Less formal, face-to-face, exit inogy examination. terviews with their service chief. 2. Faculty evaluation of the actual clin(c) Weekly 1-hr meetings with the ical records of a few patients in Clinical Core Coordinator. whose care the student has participated during the course of the rotation. Each student's written perforMETHODS—EDUCATIONAL mance on these records is evaluated STRATEGIES according to reasonably standardized criteria by faculty members Each student on the CLPCC spends most who have not had any teaching or of his /her time seeing inpatients referred other relationship with that student. for psychiatric consultation from all units Three performance areas are focused of the general hospital (see Table 1 and upon by the faculty evaluators. Fig. 1). For breadth of patient experience (a) The use of the problem oriented and resident supervision, students are not medical record in caring for pa- assigned to specific hospital units, as are tients with psychosocial prob- the C-L psychiatric residents. Receiving patients in a regular rotation, students on lems. (b) The use of a model of the average have responsibility for two psychotherapeutic intervention new inpatient consultations per week. in short term or crisis-oriented, They also see many other patients in their psychosocial care, based on an other rotation activities that are described assessment of the data and later. clearly specified treatment goals. The CLPCC student usually is the first (c) The use of commonly used person to see the assigned patient and is psychotropic drugs, with their major therapeutic effects and side effects, in the treatment of TABLE 1. Time/Activity Distribution (Average specified psychosocial problems Hours per Week) a derived from an assessment of Inpatient consultation (and follow-up) 22 the patient data base. Liaison work (staff meetings, ward Each student is given an overall performance rating of either unsatisfactory, minimally satisfactory, satisfactory, or outstanding in this standardized evaluation process, and a numerical grade on the psychopharmacology examination. Students' feedback is obtained by: (a] Required anonymous written
rounds, etc.) Attending rounds Outpatient work Primary Care Clinic Child psychiatry Seminars
4 10 2 3 4 45 hr/wk
a Plus emergency night or weekend day call at least once per rotation.
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
49
F. PATRICK MCKEGNEY AND SHELDON WEINER Fig. 1.
Monday 8:00-12:00
Patient work
Consultation-Liaison Service Clinical Core student schedule.
Tuesday 8:00-10:00
Wednesday
Patient work
8:00-9:30 Clinical Psychiatry seminar
10:00-12:00
9:30-10:30 Seminar-Clinical Core Director
Thursday
Friday
.8:00-9:00 Patient work
8:00-10:00
9:00-12:00
Patient work
10:00-12:00
10:30-12:00 Child psychiatry
12:00-1:00 Patient work 1:00-3:00
Attending rounds
Attending rounds
Attending rounds
12:00-1:00 Patient work
12:00-1:00 Patient work
1:00-3:00 Patient work Primary care Clinic or inpatient consultation
1:00-
Attending rounds 12:00-1:00 Patient work 1:00-3:00 Patient work Primary care Clinic or inpatient consultation
12:00-
Patient work
Patient work 3:00-4:00 Service Director seminar
3:00-5:00
Attending rounds
4:00Patient work
responsible for the primary workup. Early in the clerkship, a resident accompanies the student in the initial interview but a resident always sees every patient, in order to audit the student's data base. The student is expected to: (a) Obtain and record a complete psychosocial data base. (b) Thoroughly review the current and past medical records. (c) Define a complete psychosocial problem list. (d) Outline a preliminary management plan. 50
Except in the Primary Care Clinic (v.i.), the CLPCC students do not perform a complete physical examination, which usually has been done already. However, they sometimes do a neurological examination when one is not suffciently documented in the chart. When the above is completed, the student presents his findings to the resident assigned to the consultation, who then interviews the patient with the student, if he has not done so before, and audits the student's initial written workup. Following resident feedback, the student then presents his case at one of the daily attend-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
ing rounds to residents, fellow students, and the faculty attending of the day, who usually interviews the patient with the trainees. At this time, the problem list is finalized and intervention (s) agreed upon. This process is compressed in time when indicated by urgent patient care needs. The student completes the full psychosocial workup, which is written and audited by the resident according to a prescribed format and in accord with both a general psychiatric consultation miminum screening data base and one of several problem specific data bases (available upon request). The resident signs the audited and annotated student workup, and usually adds a brief summary note, emphasizing the faculty attending's recommendations. The faculty attending also adds a brief note, which certifies that he has seen the patient and agrees with the plan, and also enables him /her to bill the patient for consultation services rendered. Only these patients seen by the attending psychiatrist are billed and then only for the time actually spent in patient contact or decision-making about that patient. In these inpatient consultations, the students see the wide range of patient problems documented elsewhere (3), which is similar to the patient population of the nonpsychiatric physician's hospital practice rather than the patient population in psychiatric treatment settings. Other activities of the CLPCC students include (see Fig. 1):
(c) A weekly 3-hr child psychiatry teaching conference, in which each student has an opportunity to evaluate personally and follow through with one child-family problem situation, with other students and faculty observing. Later, all students discuss the interviews, assessments, and plans for the patient care problems with the faculty. (d) Liaison participation with faculty and residents in teaching and work rounds with members of nonpsychiatric services such as Rehabilitation Medicine, Obstetrics-Gynecology, and Renal Dialysis-Transplant services. (e) Emergency night and weekend call for the entire general hospital, with one of the C-L residents, at least two nights and /or weekend days during the rotation. (f) A minimum of one experience in assessing a person referred to the "Center for Disorders of Communication," in collaboration with a neurologist, a speech therapist, and a social worker. (g) Two sessions per rotation (2nd and 7th weeks) in which videotapes are reviewed of each student interviewing patients, toward the specific objective of observing emotional content and process in both student and patient. These reviews are done with the students in a group, supervised by a faculty member, and emphasize constructive student-to-student feedback (peer review). RESULTS
(a) A core seminar program, IVihrper week. (b) A weekly 2-3-hr Primary Care Clinic experience in which the student comprehensively evaluates and cares for ambulatory general medical patients with a psychiatrist and an internist in joint supervisory attendance.
Ideally, the assessment of the effectiveness of this new CLPCC in psychiatry would depend on the actual clinical practice behaviors of the students at least 5 years after graduation. However, in the absence of such data (which will be gathered at the appropriate time), the results of 1 full
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
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F. PATRICK MCKEGNEY AND SHELDON WEINER
clerkship year's experience were examined, using the following data gathered prospectively and independently from the faculty of the clinical services to which the individual students were assigned.
no significant differences between CLPCC students and those on other psychiatric services. Thus, the experience with "nonpsychiatric" patients does not put the CLPCC students at a disadvantage com-
1. The overall assessment of written student performance in the standardized end of rotation evaluation process described above. 2. The student scores on the psychopharmacology examination given at the end of each rotation. 3. Student opinions about the quality of their educational experiences on different psychiatric clinical services.
~ 11 i i . -r. , i.«. , Table 3 shows the significant difference betw f ? s t u d ! n t o p i n i ° n S a b o u t A e qual" ity of thmr educational experience comP a n n S ^ CLPCC students and all other psychiatry clerkship service stadents The CLPCC students, as a group fel t they had a b er f experience than did students on °^eT s e r v i c e s " " s h ° u l d b e ™ d e e x P h c i t that no criteria tor these student opinions As seen in Table 2, evaluation of the two were specified, and that these are global parameters of student performance shows ratings.subjecttoamyriadof influences. A TABLE 2.
Student Performance Measures
Student overall performance rating—January 1974-December 1974 (see text) Very satis.
Unsat.
Min satis.
C-L Service students
0
4
11
2
17
Other service (4) students •'
2
4
40
11
57
2
8
51
13
74
Satis.
X2 = 4.38; df = 3; p = 0.30 < 0.20 Psychopharmacology examination C-L Service students Other service students'1 J
88.2% 88.6%
N = 17 N = 57
Acute inpatient, outpatient, state hospital, Crisis Clinic.
TABLE 3.
Student Overall Assessment of Eductional Experience January 1974-December 1974 Clinical Core Below average
Average
Above average
C-L Service
0
7
10
17
Other services (4)'
7
37
15
59
7
44
25
76
X2 = 7.56; df = 2; p = 0.05 < 0.02 a
52
Acute inpatient, outpatient, state hospital, Crisis Clinic.
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
majority of students were generally matched to their first choice of service preference. Those who were not received assignments to all services in approximately equal proportions. Some student quotes may add unquantifiable, but illuminating, views of the CLPCC experience: "The goals were too ambitious." "The faculty and resident contacts were great." "Sometimes the work load was too heavy; I couldn't keep up. Other times it was too slow, but at least I could read all the stuff thrown at me." "My ideas about psychiatry were turned around 180 degrees by this rotation. I now realize what psychiatry can mean to me as a family practitioner." "God, I'm just beginning to see what the family physician has to deal with. It's too much!" "I wish I could have had more folow-up with patients."
(POMR), which is a systematic methodology for problem solving (4). The basic steps in the use of the POMR asre as follows. (a) The collection of information (data base] by which a problem or problems can be identified and defined. (b) The assessment of that data base at the highest possible level of understanding that would indicate an appropriate plan. (c) The specification of plans or contingencies for gathering further data, treatment, and /or patient education. (d) The delineation of constraining or augmenting factors affecting resolution of the problem. (e) The systematic recording of the outcomes of plans.
As a starting point in the use of the POMR a minimum data base has been defined for all psychiatric consultations. This minimum data base is conceptualized as being that body of knowledge that the All these measures must be put in the members of our service have agreed is funrelatively uncontrolled and time-limited damental for all consultations, as a core of context of any educational assessment ef- knowledge that we cannot afford to miss. fort. However, the CLPCC rotation is an Rather than being problem specific, the experience viewed positively by students, minimum data base is used as a screening although not without anxiety. The stu- function. In the POMR, failure to obtain dents are not "penalized" in comparison the mimimum data base is listed as a probwith the psychiatric learning of those on lem to be dealt with as any other problem. traditional psychiatric clerkship rotations. Problem specific data bases have been The longer term results will be tested by defined for a few situations, in which further medical school clinical perfor- someone's clinical judgment has mance parameters, by specialty choices, identified a broadly stated problem such as and by actual practice performance vari- "schizophrenia" or "organic brain synables. drome," which then requires the gathering of a subset of information particularly indicated for that designated problem. DISCUSSION Although interviewing is obviously an essential ingredient in the teaching Intrinsic to the CLPCC experience is the methodology, an even more major and use of the problem oriented medical record significant experience is that of the audit Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
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F. PATRICK MCKEGNEY AND SHELDON WEINER
mechanism. Audit is a means of contrasting observed behaviors with previously agreed upon expected standards. It is a feedback loop designed to ensure the best possible patient care and to maximize the provider's learning processes. As Jason has stated (5), learning without feedback is like learning to drive a car when the turn of the steering wheel is in no way related to the direction the car will go. Traditionally, an audit may take one of two forms: it may be directed toward provider behaviors or to patient outcomes. Since there is usually insufficient opportunity to follow consultation patients over a prolonged period of time, auditing patient outcome is very difficult. Thus, student or provider behaviors are audited along the the lines suggested by Weed (4), namely, thoroughness, reliability, efficiency, and analytic sense. Although the audit mechanism is at times a frustrating experience for students, in accordance with the pleasure-pain principle, surprisingly we have been criticized when students felt that the audit was not extensive or intensive enough. In the pilot phase of this clerkship, there was some negative feedback to us from attendings on other services, primarily
about the "extra" medical students seeing their patients in consultation. However, responses to a subsequent request for written feedback, from all nonpsychiatric attendings about the C-L service, were almost unanimously positive, with no mention made about the CLPCC students. In summary, a psychiatric clinical clerkship teaching experience has been described, which utilizes the Psychiatric Consultation-Liaison Service as the setting and the problem oriented medical record and audit as instructional tools. Student performance measures indicate CLPCC students perform at least as well as students on other psychiatric services in "strictly psychiatric" parameters. Many faculty feel very positively that the consultation-liasion setting is a most effective means to teach psychiatry to medical students. Faculty time expenditures have been recorded so that "service" time, and cost reimbursement, can be separated out from "teaching" effort. Finally, the student opinion feedback suggests that this educational experience may be more relevant to the effective practice of the future physician than the traditional clinical clerkship in psychiatry.
REFERENCES 1. Goodwin W: Blackouts and alcohol induced memory dysfunction, in Recent Advances in Studies of Alcoholism. Publ. #(HSM) 71-9045, 1971 2. McKegney FP:'The teaching of psychosomatic medicine: Consultation and liaison psychiatry, in Reiser MM (ed), American Handbook of Psychiatry (2nd ed), Vol. IV. New York, Basic Books, 1975, in press 3. Kligerman MJ, McKegney FP: Patterns of psychiatric consultation in two general hospitals. Psychiatry Med 2:126-132, 1971 4. Weed LL: Quality Control in Applying the Problem Oriented System (edited by Walker HK, Hurst JW, Woody MF). New York, Medom, 1973, pp. 3-13 5. Jason H: Evaluation in Medical Education. Paper presented in Burlington, Vt, October 23, 1973
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Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
THE PROBLEM Medical curriculum changes over the past decade have been extensive, particularly toward less basic science time, increased elective time, earlier specialization or "tracking," and overall compression of college, medical school, and post-M.D. training. The "internship" year
From the Department of Psychiatry, College of Medicine, University of Vermont, Burlington, Vermont 05401. "Professor of Psychiatry and Director, Consultation-Liaison Service. tProfessor and Chairman of Psychiatry, former Director, Consultation-Liaison Service. This paper was originally presented at the University of Rochester, Department of Psychiatry, Grand Rounds, February 6,1975. Work supported in part by NIMH Training Grant #2 T01 MH08052-12. Received for publication March 10,1975, revision received June 16, 1975.
as most of us have known it is being challenged. Only the traditional required clinical clerkships in the "basic" disciplines, Internal Medicine, Surgery, ObstetricsGynecology, Pediatrics, and Psychiatry, have remained relatively intact in this recent convulsion of change. To be sure, some modifications have been made in this pivotal period in the medical students' evolution into physicians. The total time devoted to these required clerkships has been somewhat decreased, and family practice or primary care clerkships have been added in some schools. However, the required clerkships generally remain unchanged, occupying a year or more in the middle of medical school, taught by research-oriented medical specialists or by interns, residents, and fellows who aspire to a similar career of "superspecialization." These clinical clerkships are usually
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976) Copyright s 1976 by the American Psychosomatic Society, Inc. Published by American Elsevier Publishing Company, Inc.
45
F. PATRICK MCKEGNEY AND SHELDON WEINER
spent on specialty inpatient services, caring for a patient population highly selected for diseases in that specialty. Only occasionally are physicians from other disciplines involved in teaching the student on the specialty-bound clerkship. Immersed in the inpatient practice of a given specialty, students rarely can extract the principles of that specialty field that are pertinent to the other fields of medicine. An absence of relevance for most future physicians is a serious deficiency in any specialty clinical clerkship. It is most regrettable in the Psychiatry Clerkship, which may be the first, and last, opportunity for the student to be intensively involved with the patient in an interpersonal-social-environmental context. However, required Psychiatry clerkships primarily expose the student to the diagnosis and treatment of "psychiatric" patients by skilled mental health professionals in a psychiatric setting. Such Psychiatry clerkships, as a result, usually fail in enabling the student to acquire the knowledge, skills, and attitudes for the observation and assessment of human behavior and appropriate personal intervention in the practice of medicine. A temporary digression into the area of state-dependent learning may further emphasize this point. This theory simply states that information learned in one state is best recalled in that same state, and is exemplified by recent studies with alcohol and chronic alcoholics. Many chronic alcoholics claim that the location of money or alcohol, which had been hidden in the course of a drinking bout for safekeeping, could not be remembered during the subequent sobriety; recall only occurred during the next immediate drinking episode. This phenomenon was experimentally confirmed by Goodwin (1) in a controlled 46
study that utilized pornographic pictures as the learned stimulus and sobriety and intoxication as the variable states. If one cannot recall pornographic pictures, should one realistically be expected to recall psychiatric principles? Thus, it can be reasoned that, if most medical students learn psychiatry in psychiatric settings, but ultimately practice in different settings, then recall of psychiatric principles will be compromised. Our prior experiences with medical students on nonpsychiatric services would seem to validate this hypothesis; the learning that they had acquired during their Psychiatric Clerkship had somehow dissipated when they moved to other clinical rotations. In summary, as in other required clinical specialty clerkships, the teaching of psychiatry has traditionally taken place on psychiatric services, with "psychiatric" patients, and has emphasized nosology, psychopathology, psychodynamics, and psychotherapy by skilled mental health professionals. As a result, the relevance and "carryover learning" of psychiatric principles as applicable to nonpsychiatric patients by future nonpsychiatrists is compromised. In an effort to improve such relevance and carryover learning, a new psychiatry clinical clerkship was begun on a pilot basis in January, 1973, and made fully operational in January, 1974. It is based on the Department of Psychiatry Consultation-Liaison Service and uses the problem oriented medical record system and audit of student performance as basic instructional tools. A description of the background or curricular matrix of this Consultation-Liaison Psychiatry Clinical Clerkship (CLPCC) will be followed by an outline of the goals, and evaluation and educational strategies as developed over 2 years. Certain student performance out-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
comes are reported for the 1 year of full operation. The University of Vermont Medical School has a 4-year program leading to the M.D. degree. Medical students have their 8-week Psychiatry Clerkship sometime during the 48-week Clinical Core, which begins in January of their second year. Prior to the Clinical Core, the students have considerable exposure to the principles of psychological medicine: in the first year a Human Behavior course (50 hr); in the second year in Human Sexuality (24 hr) and Psychopathology (26 hr) courses; and in the Basic Clerkship, or introduction to clinical medicine, in which psychiatrists take an active part, throughout the first year and a half of medical school. After the Clinical Core, students spend the last 15 months in the Senior Major Program, taking a wide range of electives, which are predominantly clinically related, selected according to their projected future careers. Students beginning the Psychiatry Clerkship spend their first day in a general orientation, which includes an introduction to the five clinical services to which they can be possibly assigned (on the basis of student quotas): an acute 32-bed, general hospital inpatient psychiatric unit (4); the emergency room-crisis clinic (2); a short term ambulatory psychiatric clinic (3); a regionalized unit of the Vermont State Hospital (2); and the C-L Service (4). Final assignments are made according to student preference, within the constraints of the service quotas, with most students receiving their first choice and the remainder usually assigned to their second choice.
culty consists of the equivalent of one and one half full-time psychiatrists and a quarter-time psychiatric nurse. The Director devotes somewhat more than half his time to the Service and five other psychiatrists teach students and residents 2-3 hr per week, on attending rounds or in the Primary Care Clinic. Two third year residents have full-time, 6-month assignments to the C-L Service and function as team leaders, being responsible for the day-today management of patients and the audit of student performance. Faculty members lead the daily attending rounds and are teachers and supervisors rather than direct providers of patient care. Student participation consists of two to four Clinical Core students who spend their 8-week clinical clerkship in psychiatry with the C-L Service, and Senior Major students who may have elected 1- or 2-month rotations. Interns and residents from other disciplines may also spend elective time on this service. Senior nursing students spend 8-12 weeks part-time on the service. The Consultation-Liaison Service attends to all psychiatric problems in the 500-bed Medical Center Hospital of Vermont, excluding the emergency room and the 32-bed inpatient unit. Approximately 500 consultations are seen annually. In addition to performing consultations, psychiatrist and nurse faculty and residents participate in staff-focused liaison activities in various medical and surgical specialties, according to principles described elsewhere (2).
GOALS
The University of Vermont College of Medicine has always emphasized the clinical practice of medicine in its educational BACKGROUND programs. The great majority of current The Consultation-Liaison Service fa- students express such an interest, with ap-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
47
F. PATRICK MCKEGNEY AND SHELDON WEINER
proximately half being most interested in family practice. All students on the Psychiatry Clerkship are expected to meet eight overall objectives with specified behavioral outcomes (available on request). Within this institutional and student interest context, the Consultation-Liaison Psychiatry Clinical Clerkship (CLPCC) is designed to enable the student to acquire the knowledge, skills, and attitudes of the field of psychiatry that are most relevant to the practice of medicine in fields other than the specialty of psychiatry, particularly in the field of primary care or family practice. The particular goals of the CLPCC are to enable the student:
9. To accept peer audit and to develop techniques of self-audit, toward meaningful continuing education in the practice of medicine. METHODS—EVALUATION STRATEGIES
The basic evaluation strategies of the CLPCC involve (a) individual and group supervision of a student's performance in working with patients and in discussions with peers and supervisors and (b) audit of the student's written performance using the problem oriented medical record (POMR). This supervision and audit are largely carried out by the residents and faculty of the C-L Service, although an increasing emphasis is being placed on faculty supervision of a student peer audit process. It is hoped that this latter technique will enhance the development of selfevaluative skills for ongoing continuing education, and a positive attitude toward peer review processes in the future practice of medicine. Thus, the day-to-day student evaluation and education is carried out by frequent, immediate, and personal feedback to the students about their performance in the process of clinical work relevant to both patient and student and in the context of clear objectives and criteria for performance. In addition, the C-L Service Director provides evaluative feedback pooled from the residents and other faculty in a weekly group meeting of all CLPCC students and in a twice-perrotation individual meeting with each student.
1. To gather a reliable and comprehensive psychosocial data base, both subjective (historical) and objective (mental status); 2. To define a psychosocial problem list and relate these problems to the patient's overall health /disease status; 3. To assess a patient's problems in terms of clinical, dynamic, psychogenetic, and biological formulations; 4. To develop treatment plans for the patient's problems that are practical and could feasibly be carried out by the primary care physician; 5. To develop interpersonal skills with a wide range of patients in order to meet the above goals most effectively; 6. To develop basic psychotherapeutic skills with patients and families appropriate for the primary care physician; 7. To be able to use psychopharmacologic interventions in a wide range of Near the end of each rotation all stuproblems; dents participate in a standardized evalua8. To be able to carry out an effective tion process that has two components: referral of patients to other resources appropriate to the treatment plan, including 1. A formal half-day session in which referral to a psychiatrist; students: 48
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
opinions about the quality of (a) Do problem oriented data bases and assessments of one written their educational experience on case history and four videotaped their rotational service and qualpatient interviews. ity of their individual supervisors. (b) Complete a 25-item National Board-type psychopharmacol(c) Less formal, face-to-face, exit inogy examination. terviews with their service chief. 2. Faculty evaluation of the actual clin(c) Weekly 1-hr meetings with the ical records of a few patients in Clinical Core Coordinator. whose care the student has participated during the course of the rotation. Each student's written perforMETHODS—EDUCATIONAL mance on these records is evaluated STRATEGIES according to reasonably standardized criteria by faculty members Each student on the CLPCC spends most who have not had any teaching or of his /her time seeing inpatients referred other relationship with that student. for psychiatric consultation from all units Three performance areas are focused of the general hospital (see Table 1 and upon by the faculty evaluators. Fig. 1). For breadth of patient experience (a) The use of the problem oriented and resident supervision, students are not medical record in caring for pa- assigned to specific hospital units, as are tients with psychosocial prob- the C-L psychiatric residents. Receiving patients in a regular rotation, students on lems. (b) The use of a model of the average have responsibility for two psychotherapeutic intervention new inpatient consultations per week. in short term or crisis-oriented, They also see many other patients in their psychosocial care, based on an other rotation activities that are described assessment of the data and later. clearly specified treatment goals. The CLPCC student usually is the first (c) The use of commonly used person to see the assigned patient and is psychotropic drugs, with their major therapeutic effects and side effects, in the treatment of TABLE 1. Time/Activity Distribution (Average specified psychosocial problems Hours per Week) a derived from an assessment of Inpatient consultation (and follow-up) 22 the patient data base. Liaison work (staff meetings, ward Each student is given an overall performance rating of either unsatisfactory, minimally satisfactory, satisfactory, or outstanding in this standardized evaluation process, and a numerical grade on the psychopharmacology examination. Students' feedback is obtained by: (a] Required anonymous written
rounds, etc.) Attending rounds Outpatient work Primary Care Clinic Child psychiatry Seminars
4 10 2 3 4 45 hr/wk
a Plus emergency night or weekend day call at least once per rotation.
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
49
F. PATRICK MCKEGNEY AND SHELDON WEINER Fig. 1.
Monday 8:00-12:00
Patient work
Consultation-Liaison Service Clinical Core student schedule.
Tuesday 8:00-10:00
Wednesday
Patient work
8:00-9:30 Clinical Psychiatry seminar
10:00-12:00
9:30-10:30 Seminar-Clinical Core Director
Thursday
Friday
.8:00-9:00 Patient work
8:00-10:00
9:00-12:00
Patient work
10:00-12:00
10:30-12:00 Child psychiatry
12:00-1:00 Patient work 1:00-3:00
Attending rounds
Attending rounds
Attending rounds
12:00-1:00 Patient work
12:00-1:00 Patient work
1:00-3:00 Patient work Primary care Clinic or inpatient consultation
1:00-
Attending rounds 12:00-1:00 Patient work 1:00-3:00 Patient work Primary care Clinic or inpatient consultation
12:00-
Patient work
Patient work 3:00-4:00 Service Director seminar
3:00-5:00
Attending rounds
4:00Patient work
responsible for the primary workup. Early in the clerkship, a resident accompanies the student in the initial interview but a resident always sees every patient, in order to audit the student's data base. The student is expected to: (a) Obtain and record a complete psychosocial data base. (b) Thoroughly review the current and past medical records. (c) Define a complete psychosocial problem list. (d) Outline a preliminary management plan. 50
Except in the Primary Care Clinic (v.i.), the CLPCC students do not perform a complete physical examination, which usually has been done already. However, they sometimes do a neurological examination when one is not suffciently documented in the chart. When the above is completed, the student presents his findings to the resident assigned to the consultation, who then interviews the patient with the student, if he has not done so before, and audits the student's initial written workup. Following resident feedback, the student then presents his case at one of the daily attend-
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
ing rounds to residents, fellow students, and the faculty attending of the day, who usually interviews the patient with the trainees. At this time, the problem list is finalized and intervention (s) agreed upon. This process is compressed in time when indicated by urgent patient care needs. The student completes the full psychosocial workup, which is written and audited by the resident according to a prescribed format and in accord with both a general psychiatric consultation miminum screening data base and one of several problem specific data bases (available upon request). The resident signs the audited and annotated student workup, and usually adds a brief summary note, emphasizing the faculty attending's recommendations. The faculty attending also adds a brief note, which certifies that he has seen the patient and agrees with the plan, and also enables him /her to bill the patient for consultation services rendered. Only these patients seen by the attending psychiatrist are billed and then only for the time actually spent in patient contact or decision-making about that patient. In these inpatient consultations, the students see the wide range of patient problems documented elsewhere (3), which is similar to the patient population of the nonpsychiatric physician's hospital practice rather than the patient population in psychiatric treatment settings. Other activities of the CLPCC students include (see Fig. 1):
(c) A weekly 3-hr child psychiatry teaching conference, in which each student has an opportunity to evaluate personally and follow through with one child-family problem situation, with other students and faculty observing. Later, all students discuss the interviews, assessments, and plans for the patient care problems with the faculty. (d) Liaison participation with faculty and residents in teaching and work rounds with members of nonpsychiatric services such as Rehabilitation Medicine, Obstetrics-Gynecology, and Renal Dialysis-Transplant services. (e) Emergency night and weekend call for the entire general hospital, with one of the C-L residents, at least two nights and /or weekend days during the rotation. (f) A minimum of one experience in assessing a person referred to the "Center for Disorders of Communication," in collaboration with a neurologist, a speech therapist, and a social worker. (g) Two sessions per rotation (2nd and 7th weeks) in which videotapes are reviewed of each student interviewing patients, toward the specific objective of observing emotional content and process in both student and patient. These reviews are done with the students in a group, supervised by a faculty member, and emphasize constructive student-to-student feedback (peer review). RESULTS
(a) A core seminar program, IVihrper week. (b) A weekly 2-3-hr Primary Care Clinic experience in which the student comprehensively evaluates and cares for ambulatory general medical patients with a psychiatrist and an internist in joint supervisory attendance.
Ideally, the assessment of the effectiveness of this new CLPCC in psychiatry would depend on the actual clinical practice behaviors of the students at least 5 years after graduation. However, in the absence of such data (which will be gathered at the appropriate time), the results of 1 full
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F. PATRICK MCKEGNEY AND SHELDON WEINER
clerkship year's experience were examined, using the following data gathered prospectively and independently from the faculty of the clinical services to which the individual students were assigned.
no significant differences between CLPCC students and those on other psychiatric services. Thus, the experience with "nonpsychiatric" patients does not put the CLPCC students at a disadvantage com-
1. The overall assessment of written student performance in the standardized end of rotation evaluation process described above. 2. The student scores on the psychopharmacology examination given at the end of each rotation. 3. Student opinions about the quality of their educational experiences on different psychiatric clinical services.
~ 11 i i . -r. , i.«. , Table 3 shows the significant difference betw f ? s t u d ! n t o p i n i ° n S a b o u t A e qual" ity of thmr educational experience comP a n n S ^ CLPCC students and all other psychiatry clerkship service stadents The CLPCC students, as a group fel t they had a b er f experience than did students on °^eT s e r v i c e s " " s h ° u l d b e ™ d e e x P h c i t that no criteria tor these student opinions As seen in Table 2, evaluation of the two were specified, and that these are global parameters of student performance shows ratings.subjecttoamyriadof influences. A TABLE 2.
Student Performance Measures
Student overall performance rating—January 1974-December 1974 (see text) Very satis.
Unsat.
Min satis.
C-L Service students
0
4
11
2
17
Other service (4) students •'
2
4
40
11
57
2
8
51
13
74
Satis.
X2 = 4.38; df = 3; p = 0.30 < 0.20 Psychopharmacology examination C-L Service students Other service students'1 J
88.2% 88.6%
N = 17 N = 57
Acute inpatient, outpatient, state hospital, Crisis Clinic.
TABLE 3.
Student Overall Assessment of Eductional Experience January 1974-December 1974 Clinical Core Below average
Average
Above average
C-L Service
0
7
10
17
Other services (4)'
7
37
15
59
7
44
25
76
X2 = 7.56; df = 2; p = 0.05 < 0.02 a
52
Acute inpatient, outpatient, state hospital, Crisis Clinic.
Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
A CONSULTATION-LIAISON PSYCHIATRY CLINICAL CLERKSHIP
majority of students were generally matched to their first choice of service preference. Those who were not received assignments to all services in approximately equal proportions. Some student quotes may add unquantifiable, but illuminating, views of the CLPCC experience: "The goals were too ambitious." "The faculty and resident contacts were great." "Sometimes the work load was too heavy; I couldn't keep up. Other times it was too slow, but at least I could read all the stuff thrown at me." "My ideas about psychiatry were turned around 180 degrees by this rotation. I now realize what psychiatry can mean to me as a family practitioner." "God, I'm just beginning to see what the family physician has to deal with. It's too much!" "I wish I could have had more folow-up with patients."
(POMR), which is a systematic methodology for problem solving (4). The basic steps in the use of the POMR asre as follows. (a) The collection of information (data base] by which a problem or problems can be identified and defined. (b) The assessment of that data base at the highest possible level of understanding that would indicate an appropriate plan. (c) The specification of plans or contingencies for gathering further data, treatment, and /or patient education. (d) The delineation of constraining or augmenting factors affecting resolution of the problem. (e) The systematic recording of the outcomes of plans.
As a starting point in the use of the POMR a minimum data base has been defined for all psychiatric consultations. This minimum data base is conceptualized as being that body of knowledge that the All these measures must be put in the members of our service have agreed is funrelatively uncontrolled and time-limited damental for all consultations, as a core of context of any educational assessment ef- knowledge that we cannot afford to miss. fort. However, the CLPCC rotation is an Rather than being problem specific, the experience viewed positively by students, minimum data base is used as a screening although not without anxiety. The stu- function. In the POMR, failure to obtain dents are not "penalized" in comparison the mimimum data base is listed as a probwith the psychiatric learning of those on lem to be dealt with as any other problem. traditional psychiatric clerkship rotations. Problem specific data bases have been The longer term results will be tested by defined for a few situations, in which further medical school clinical perfor- someone's clinical judgment has mance parameters, by specialty choices, identified a broadly stated problem such as and by actual practice performance vari- "schizophrenia" or "organic brain synables. drome," which then requires the gathering of a subset of information particularly indicated for that designated problem. DISCUSSION Although interviewing is obviously an essential ingredient in the teaching Intrinsic to the CLPCC experience is the methodology, an even more major and use of the problem oriented medical record significant experience is that of the audit Psychosomatic Medicine Vol. 38, No. 1 (January-February 1976)
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F. PATRICK MCKEGNEY AND SHELDON WEINER
mechanism. Audit is a means of contrasting observed behaviors with previously agreed upon expected standards. It is a feedback loop designed to ensure the best possible patient care and to maximize the provider's learning processes. As Jason has stated (5), learning without feedback is like learning to drive a car when the turn of the steering wheel is in no way related to the direction the car will go. Traditionally, an audit may take one of two forms: it may be directed toward provider behaviors or to patient outcomes. Since there is usually insufficient opportunity to follow consultation patients over a prolonged period of time, auditing patient outcome is very difficult. Thus, student or provider behaviors are audited along the the lines suggested by Weed (4), namely, thoroughness, reliability, efficiency, and analytic sense. Although the audit mechanism is at times a frustrating experience for students, in accordance with the pleasure-pain principle, surprisingly we have been criticized when students felt that the audit was not extensive or intensive enough. In the pilot phase of this clerkship, there was some negative feedback to us from attendings on other services, primarily
about the "extra" medical students seeing their patients in consultation. However, responses to a subsequent request for written feedback, from all nonpsychiatric attendings about the C-L service, were almost unanimously positive, with no mention made about the CLPCC students. In summary, a psychiatric clinical clerkship teaching experience has been described, which utilizes the Psychiatric Consultation-Liaison Service as the setting and the problem oriented medical record and audit as instructional tools. Student performance measures indicate CLPCC students perform at least as well as students on other psychiatric services in "strictly psychiatric" parameters. Many faculty feel very positively that the consultation-liasion setting is a most effective means to teach psychiatry to medical students. Faculty time expenditures have been recorded so that "service" time, and cost reimbursement, can be separated out from "teaching" effort. Finally, the student opinion feedback suggests that this educational experience may be more relevant to the effective practice of the future physician than the traditional clinical clerkship in psychiatry.
REFERENCES 1. Goodwin W: Blackouts and alcohol induced memory dysfunction, in Recent Advances in Studies of Alcoholism. Publ. #(HSM) 71-9045, 1971 2. McKegney FP:'The teaching of psychosomatic medicine: Consultation and liaison psychiatry, in Reiser MM (ed), American Handbook of Psychiatry (2nd ed), Vol. IV. New York, Basic Books, 1975, in press 3. Kligerman MJ, McKegney FP: Patterns of psychiatric consultation in two general hospitals. Psychiatry Med 2:126-132, 1971 4. Weed LL: Quality Control in Applying the Problem Oriented System (edited by Walker HK, Hurst JW, Woody MF). New York, Medom, 1973, pp. 3-13 5. Jason H: Evaluation in Medical Education. Paper presented in Burlington, Vt, October 23, 1973
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