Dr. Brodkey is clinical associate professor and Dr. Van Zant is clinical associate professor; both in the Department of Psychiatry, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania. Dr. Sierles is professor and chair, Department of Psychiatry and Behavioral Sciences, Finch University of Health Sciences, The Chicago Medical School, North Chicago, Illinois. Requests for reprints should be sent to Dr. Brodkey, Department of Psychiatry, Friends Hospital, 4641 Roosevelt Blvd., Philadelphia, PA 19124.
Copyright © 1997, Academic Psychiatry.
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The formulation and subsequent use of objectives for the MCP psychiatry clerkship
illustrate their benefits for a departmental teaching program. In 1992, the director
of medical student education (ACB) and assistant clerkship director (KVZ) perceived
a need for such objectives for the reasons detailed earlier and to improve teaching
and evaluation in the clerkship. Although students had previously rated their clinical
experience highly, they had complained about the didactic portion of the curriculum
and the validity of the final examination. No formal objectives were used. We wrote
first drafts and distributed these to faculty who taught clerks. In a series of meetings,
several drafts were discussed and revised.
Initially, the project engendered confusion and skepticism. Concerns included that
the document might emphasize academic performance at the expense of clinically meaningful
experience, favor accumulation of knowledge over attitude change and skill acquisition,
or stifle serendipitous and self-directed learning. Some faculty were uncomfortable
with formal expectations of students, and some doubted this diverse group could achieve
consensus. As time passed, most participants were reassured that their opinions were
taken seriously, that the group could agree much of the time, and that objectives
could encompass important noncognitive factors (14).
This resolution led to a second phase, articulating the educational purposes of the
clerkship. Three guiding principles for inclusion of objectives emerged. Most important
was the question of what a future generalist must know to adequately diagnose, and
treat or refer, psychiatric problems he or she will likely encounter in future practice.
Addressing this issue required knowledge of psychiatric epidemiology, presentations
of psychopathology in primary care settings, and the stated educational needs of
generalists (15-18). Second was the desire to acquaint students with psychiatry's
scientific foundation and role as a medical specialty. We thereby hoped to decrease
prejudice against the field, its practitioners, and its patients. Finally, a certain
configuration was imposed by our department's resources and interests. For example,
objectives on sleep disorders were excluded because this subject is taught by other
MCP departments. We debated the boundaries between the clerkship and other departmental
offerings, and between psychiatry and other disciplines.
Many interesting and intense discussions ensued, occasionally requiring that subgroups
work on sections of the document. We became more adept as we worked through several
drafts, ́losing" only one participant because of irreconcilable differences.
As we proceeded, "minimalist" expectations were replaced by more idealistic
ones.
We began using the objectives in July 1993. The students were told that the objectives
were intended to guide their study, representing what we thought a medical school
graduate ideally should know about psychiatry. They were not expected to master all
objectives during the 6-week clerkship, and the students were encouraged to use whatever
texts and other resources they chose to achieve their goals. The didactic
portion of the clerkship and the final examination were keyed to the objectives.
Copies were also distributed to all faculty and residents. Faculty lecturers, almost
all of whom had helped to formulate the objectives, understood that their lectures
should respond to these stated expectations.
Although it was easier to incorporate the knowledge objectives into the clerkship
curriculum, efforts were made to address the behavioral and attitudinal ones as well.
For instance, the psychiatric interview course referred to the objectives for interviewing
skills. An interview rating checklist based on these objectives was given to students
and used by attending supervisors to evaluate a live or videotaped interview, which
formed part of the final evaluation. In addition, students were taught and practiced
skills in giving and receiving critiques of their interview technique. This exercise
attempted to realize several objectives from the "Attitudes, Perspectives, and
Personal Development" section on evaluating one's own performance, using and
providing constructive criticism, and demonstrating respect and empathy for patients
and colleagues. In these cases, the objectives reduced the perceived distance between
the teaching of "process" and "content" by specifying both the
content of the process and the behavioral application of the content.
Evaluation by the students of the objectives themselves has been largely positive;
on average they are rated "good" (4 on a 5-point scale). Informal feedback
suggests that they are very helpful to some students and not used much by others,
consistent with the literature on student use (19). Unfortunately, sufficient comparable
data regarding student rating of the overall clerkship experience before and after
the objectives were used are not available. However, student evaluation of all junior
clerkships from 11 "blocks" from November 1991 through June 1994, conducted
by the Office of Medical Education, revealed that psychiatry was the highest ranked
clinical clerkship, receiving the highest scores in 6 of 7 items. Two items directly
related to the objectives: "objectives, expectations, and evaluation procedures
for my performance were provided" and "the clerkship gave me an adequate
base of knowledge and skills in this discipline." The well-organized teaching
program was consistently cited in the students' comments.
Studies of objectives in medical education suggest that faculty input into, and use
of, objectives is related both to improvements in teaching and to student use of
them (20,21). Semistructured interviews regarding the effect of the process and their
subsequent use were conducted with 10 MCP faculty in the spring of 1994. The interviewees
ranged widely in academic rank and included two who had not worked on the objectives.
Over 80% of the clerkship lecturers and attending physicians and all service divisions
were represented in the sample.
Several themes emerged repeatedly. First was the unanimous perception that the project
was worth the effort, produced a valuable teaching aid, and benefited the participants
personally. All faculty interviewed used the objectives, adapting them to fit their
own circumstances, values, and styles. All used them in preparing lectures, but other
uses were reported as well, such as reading sections to reinforce clinical teaching,
or using them while reviewing students' written histories. Some stated they used
objectives they particularly liked or that fit the style or setting of their instruction.
Benefits to teaching that were mentioned included increased focus, more appropriate
level of instruction, and greater reinforcement of targeted material. Several reported
more confidence in their teaching; one person commented that, whereas students frequently
had walked out on his prior lectures, they now appeared interested because he was
teaching "the right stuff." Faculty seemed to take their teaching role
more seriously because they felt responsible for a part of the curriculum they had
helped to formulate. Several wanted to make changes and additions to respond to student
needs.
In general, a faculty member's level of participation in writing the objectives predicted
his or her subsequent use of them. Some primarily used sections they had helped to
develop and seemed to feel "ownership" of these. Several commented on how
important it was that the objectives were not externally imposed, and some stated
that having participated in the process made them easier to remember. The two subjects
who used the objectives the least had not participated in drafting them. One of these
reported being taken to task by students for initially failing to use them for her
lecture.
Benefits to the administration of the clerkship included increased focus in teaching
and assessment, greater confidence and authority because of group accountability
and collegiality, and more efficiency in communicating teaching goals. In some cases,
the benefit of formulating and using objectives seemed to generalize to other aspects
of teaching. One participant stated, "the process made me think about working
in groups for educational administration." He subsequently started an educational
steering committee at his hospital and used a similar process to formulate objectives
for the hospital's residency. Many interviewees commented that, with increased familiarity
with writing and using the objectives, they found them useful in other courses. One
subject prepared and used the objectives in studying for her psychiatry boards.
Having been a part of this process made some faculty, particularly younger and geographically
dispersed members, feel more a part of the department, and several people commented
on their increased sense of
shared mission. On the other hand, one interviewee "felt I was in the minority,"
and another "wished I had pushed my point of view harder."
All interviewees saw a need to update the objectives periodically. Organic metaphors
abounded: one teacher commented, "the objectives are sort of living things to
me," and another said "they need to be revised every year, like a garden."
It would appear that, for faculty, the process was as important as the product.
Finally, concern that these detailed objectives would intimidate faculty and students
has waned. With practice, people learned to use them to their advantage. Only one
faculty member felt they were too detailed and suggested they be prioritized. Two
felt that more emphasis should be placed on attitudinal and behavioral objectives.
However, several were pleased that the objectives were detailed: "it is especially
important in psychiatry because of the perception that we aren't real doctors and
we don't have a lot to teach" and "it's worthwhile to have a higher goal
than can be achieved." Several commented that the objectives probably would
not be used much by students unless their use was reinforced by faculty, a conclusion
that has been reached by others (20).
In 1993, Dr. Sierles, then president of ADMSEP requested copies of the objectives
that were being used by members in their junior psychiatry clerkships. The objectives
that had been developed at MCP were felt to sufficiently encompass those submitted
by medical student educators from the 45 responding schools to serve as a first draft
of a comprehensive ADMSEP-sponsored document. These were revised and edited by the
three authors, and topics and objectives were added from other departments' submissions.
Subsequently, these objectives were presented to, and deliberated by, attendees of
ADMSEP's annual meeting in June 1994. Key issues included whether such a document
was needed, whether the objectives should reflect bare bones essentials or a high
standard of knowledge and skill, and whether they should encompass a 4-year psychiatry
and behavioral science curriculum or be confined to the clerkship. In addition, Dr.
Michael Weissberg presented the University of Colorado medical student log (22),
which described 10 core supervised experiences required of their clerks (e.g., "assessing
a patient for suicide or homicide risk"). The complementarity of the detailed
MCP/ADMSEP objectives and Colorado's "experiential" log was noted. A committee
for psychiatry clerkship objectives was appointed.
Copies of the objectives and log were then sent to all ADMSEP members along with
a questionnaire soliciting impressions of the project and suggestions for revision.
Overall, the membership supported the undertaking. Many suggested changes were considered
and included.
The committee had concerns similar to those faced at MCP. First, the relatively high
level of knowledge and skill expected might be too idealistic, even quixotic. We
concluded that the level of detail was no greater than that of the surgical, gynecologic,
and pediatric objectives and that diluting them would reinforce the idea that psychiatry
had little substance. In addition, each objective was felt to be clinically important,
attainable, covered in standard texts, and testable. The decision to abjure a minimalist
standard was based on the demonstrated need for more sophisticated psychiatric practice
in primary care settings. Finally, it was felt that these objectives should be viewed
in the context of a 4-year curriculum in psychiatry and behavioral science. Some
objectives might be addressed in preclinical courses (e.g., behavioral science, introduction
to clinical medicine, neuroscience, and psychopathology) and in other clerkships.
There is no expectation that any student will master them during a clerkship. They
were meant to guide learning, representing what, ideally, a medical school graduate
should know about psychiatry.
We also discussed whether these objectives should represent a formal national clerkship
curriculum. Although produced and endorsed by ADMSEP, we expected that each school
would use or not use them based on its unique history, philosophy, and resources.
Because formulating and editing such a document de novo requires so much time and
effort, we thought many departments might use them as a starting point for discussion
and consensus development regarding their school's clerkship. Although these objectives
were intended only as a guide, we were struck by the remarkable degree of agreement
on psychiatry clerkship objectives among the different schools.
A final consideration pertained to the educational advantages and potential pitfalls
of objectives. One ADMSEP member was concerned about the potential for teacher-generated
objectives to restrict learning and discourage creative risk-taking by constraining
self-directed education and implying that objectives are a ceiling for learning.
Objectives are not individualized to the student's unique aptitudes and interests,
and "universal" objectives do not account for departmental differences.
Clinical experience is opportunistic and cannot be rigorously controlled (23). However,
the literature on objectives suggests that many pitfalls can be avoided with correct
construction and appropriate use (19-21, 24,25). In fact, even problem-based learning
programs, which focus on student-centered learning, widely use objectives in preparing
clinical cases. Objectives should be written at the appropriate level of difficulty
for students using them, neither too easy nor discouragingly unattainable. As well,
they should avoid the extremes of overgeneralization and vagueness on one hand, excessive
detail and inclusiveness on the other (26,27). Care must be taken to formulate some
objectives requiring more complex levels of thought, attitude, and behavior ("higher
order objectives") to deemphasize the memorization of facts (28). We attempted
to follow these guidelines in writing and editing the ADMSEP objectives, which are
shown in the Appendix.
Our experience formulating and using learning objectives in the psychiatry clerkship
at MCP illustrates the positive effects of this process on the learning environment,
particularly on the faculty. Much of the benefit appears to be derived from the process
of articulating the objectives, implying the need for continued active use and revision.
We hope that the ADMSEP objectives will serve as a starting point for similar reviews
at other schools.
The authors thank Cindy Sinvani for her assistance in manuscript preparation.
Portions of this paper were presented at the 1994 Association of Directors of Medical
Student Education in Psychiatry annual meeting in Tucson, Arizona, and at the 1995
annual meeting of the American Psychiatric Association in Miami Beach, Florida.
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