One often-overlooked consequence of a decade of upheaval in the health care system is that the dramatic drop in the number of psychiatrically ill patients treated in hospitals prevents medical students from being exposed to a broad range of mental illnesses during their psychiatry clerkships.

While many medical schools still send their students to inpatient units for their psychiatry rotations, several programs are introducing innovative settings in which these future physicians can learn about and treat a wider array of mentally ill patients. They foster learning in outpatient rather than inpatient settings. At the June meeting of the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), in Santa Fe, N.M., several clerkship directors discussed these new training options.

At the University of California, San Francisco’s Langley Porter Psychiatric Institute, David H. Taylor, M.D., and his colleagues decided that third-year students would benefit from rotating through an outpatient psychopharmacology clinic. This would, he noted, meet the dual goals of exposing medical students to outpatients with whom they could work on a one-to-one basis and educating them about the intricacies of psychoactive drugs.

The psychopharmacology clinic, which is part of Langley Porter’s Continuing Care Clinic, helps the students gain firsthand knowledge of what it is like to work in a managed care environment while they also learn how to work with therapists and patients’ families, said Taylor. He is assistant director of the adult psychiatry clinic at Langley Porter.

The clinic is held four days a week for two-and-a-half hours each time. Students spend two hours in patient care activities and then 30 minutes in rounds or conferences. The clinic is staffed by two or three psychiatry attendings, six psychiatry residents, two primary care residents, and a clinical pharmacist. The students receive "real-time" supervision at all decision-making levels, Taylor pointed out, and patients whom the students see are "carefully selected by the attending psychiatrists as appropriate for students."

The students usually get to see two or three patients per clinic, with visits scheduled for 30 minutes. In most patient sessions, the student sees the patient for 15 minutes, leaves the consulting room to present the case to the attending, and then, accompanied by the attending or a resident, returns to the patient to complete the session. The patient’s usual caregiver presents the student to the patient at the initial visit, Taylor explained.

Among the program’s advantages, he said, are that students see patients with a wide variety of psychiatric disorders, can join the clinic for any amount of time during their clerkship, can work at their own pace, and have the chance to "shadow residents and observe" in addition to treating patients.

Also crucial to their training is that students "are able to see patients over time," which provides the opportunity to observe changes in patients’ illnesses, witness responses to medications, and gain experience with relapsing illnesses. It is also long enough that they can "experience aspects of attachment and termination," Taylor said.

The clinic has received a warm reception from the medical students, who, he said, "feel a heightened sense of responsibility, advocacy, and concern for their outpatients." It is also popular with the attendings and residents. They have noted that it enhances the care of difficult patients and adds to the "camaraderie of the clinic."

At another branch of the University of California, this one in Davis, Martin Leamon, M.D., and Paul Cox, M.D., oversee a psychiatry clerkship in the local county jail system.

Leamon suggested at the ADMSEP meeting that since the country’s correctional systems are becoming home to a rapidly growing population of mentally ill people, "such settings become increasingly viable training sites for medical students in psychiatry."

The outpatient clerkship that Leamon and Cox oversee—and, Cox noted, "we do recognize the irony of considering the jail outpatient"—is an eight-week rotation split between two local corrections sites. There are from 12 to 20 students in each psychiatry rotation cycle, and between two and six students rotate through the jail at each session, Cox pointed out. The jail contains both men’s and women’s units.

Enrollment in the jail clerkship is largely but not entirely voluntary. Students submit their preferred rotation site and "sometimes they are honored and sometimes not," Leamon noted. "It’s a semi-random distribution." There appears to be no gender differences in the number of students choosing the jail clerkship, he added.

Students may treat patients in their cells, in the psychiatry department, or in meeting rooms off of a central day room or "pod," Leamon said. In rare instances where the patient poses a high-security risk, students may have had to deliver treatment through the patient’s cell door. Students are taught to use psychopharmacological treatments, brief psychotherapies, and crisis intervention. Students generally do not see patients who are in the midst of long-term treatment, he noted.

An evaluation that he and Cox conducted found no "negative impact" on students from spending their psychiatry clerkship in a jail. Students did not rate their experience any differently from colleagues who did not rotate through the jail, nor did they differ on the results of their written and oral clerkship examinations, Leamon said.

Students at Harvard Medical School can take advantage of yet another nontraditional clerkship site, this one at a psychiatric day hospital.

Students have the option of rotating through the Massachusetts Mental Health Center’s day hospital, which leans toward the inpatient side of the treatment continuum, but is actually a "hybrid that offers a variety of interesting experiences for the medical students," said Robert Goisman, M.D., who is director of residency training and medical student education at the mental health center. He is also director of the Harvard-Longwood psychiatry clerkship program.

In this clerkship setting, where patients stay longer than the students, the mostly fourth-year students get to observe their patients’ progress over a long enough period to witness responses to therapy and evolution of the disorder over time to a greater extent than they can in most psychiatry rotations, he noted.

Students spend one month in the clerkship (patients stay in the day hospital about three months) during which they are assigned to a multidisciplinary team headed by a psychiatry attending. The students work most closely with a PGY-2 psychiatry resident, Goisman said, and are exposed to the broad range of treatment modalities the day hospital uses, including individual and group psychotherapy, cognitive-behavioral and other psychodynamic therapies, family interventions, and psychopharmacology.

They spend one week in each of three treatment tracks, each track specializing in a different type of psychotherapy. Most of the treatment occurs in group therapy sessions that operate "more like a psychoeducation classroom than traditional group therapy," Goisman explained. During the fourth and final clerkship week students present to or co-lead a group in one of the tracks.

While being supervised, students act as patients’ primary clinician, and because of the psychoeducation emphasis, "they develop an identification as a health educator, which is consonant with the historical role of physicians," Goisman said.

Even students who do not elect to specialize in psychiatry find it rewarding, he noted, particularly those who go into family or primary medicine and find that the clerkship resembles the kind of patient interactions they anticipate in those fields. The program is "a nice marriage between the goals of a psychiatry clerkship and those of general medical education," he said.