Summer 1997 - Beyond the Hospital: Teaching Medical Students in the Community

xxAACP Newsletter, Volume 11, Number 3, Summer 1997

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Beyond the Hospital:
Teaching Medical Students in the Community

The Department of Psychiatry at the University of Florida has recently developed a component of the psychiatric clerkship which seeks to provide third-year medical students a clinical experience which is markedly different from the academic center's psychiatric inpatient setting. With decreasing lenghts of stay and increasing acuity in teaching hospitals, there have been initiatives in recent years to move more of clinical medical education into the ambulatory care setting. The primary objective at the University of Florida is to develop an outpatient, community-based clinical experience in psychiatry which exposes medical students to a patient population suffering from psychiatric disorders which they will most likely encounter in their future practice, regardless of their medical specialties. Since only a small percentage of these students will choose psychiatry as a career, the community-based, ambulatory setting is designed to provide a more tailored education regarding the evaluation and treatment of many of the common psychiatric disorders the primary care physician and specialist encounter in daily practice.

The placement of the clerkship in a medically underserved, rural community developed as part of the department's ongoing attempt to initiate an academic-public sector liaison with the public community mental health center (CMHC). A faculty member from the department spends several days a week evaluating and treating patients in an outpaitent, rural counseling center which is under the auspices of the local CMHC.

This clerkship experience in ambulatory, community-based psychiatric care was initiated in July 1996. It was designed and implemented as a Minor Rotation involving four medical students. A pair of students spend one day per week at the ambulatory clinic throughout their six-week clerkship experience. (The remainder of their time, or Major Rotation, is spent on the inpatient unit at the university hospital.) The students are under the direct supervision of the faculty member who is the attending psychiatrist at the clinic. Patients are routinely seen every thirty minutes by the attending and the two medical students. Taking turns, one medical student will be responsible for the patient review and evaluation with appropriate guidance and follow-up provided by the attending. Through this process, each medical student has the opportunity to practice their clinical interviewing skills, apply theoretical psychiatric knowledge directly to patient care, and receive direct and timely feedback from the attending. Moreover, because this is an ambulatory setting based in a rural community, the students are encouraged to develop psychiatric treatment plans which are truly biopsychosocial in nature. In other words, assesssments are developed to take into account more than just the complex symptoms and the appropriateness of particular medications. Rather, the medical students are taught how to elicit information of a psychosocial nature which may be contributing to the patient's clinical presentation or will influence the treatment plan.

Thus far the formal evaluations of the ambulatory, community-based experience in psychiatry have been consistently excellent. However, this initial model will be used to better assess how an ambulatory clerkship will impact upon thet psychiatric knowledge, skills and attitudes of the third-year students when compared to those students who completed their rotation on an inpatient unit. Additionallly, the greatest drawback to the experience has been the limit placed on the number of students who can participate during the course of the six-week clerkship. There is an obvious need to address the "inefficiencies" encountered in the outpatient teaching setting when a faculty member can supervise a relatively small number of students. Presently, only a portion of the students in each clerkship class can participate due to the lack of available faculty who practice in community-based ambulatory settings. However, in light of the overwhelming positive response displayed by the medical students during this initial implementation phase, discussions are underway in the department to develop additional community-based options which may involve non-faculty preceptors.

Richard Christensen, MD

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