Community Psychiatry and Medical Student Education

Third-year medical student clerkships in psychiatry more often than not take place on busy inpatient units affiliated with large academic medical centers. However, in this contemporary era of health care cost-containment, patients who meet criteria for a brief inpatient hospitalization are either acutely psychotic or at high risk of imminent suicide, or both. Thus most medical students are exposed to the contemporary inpatient psychiatry practice in which the aim is to rapidly stabilize individuals with institutional structure and pharmacologic interventions. The student's first—and sometimes only—experience of clinical psychiatry is one that is simultaneously emergent and crisis driven.

Unfortunately, an inpatient psychiatric population bears little resemblance to the patients whom medical students will commonly treat in their future medical practices. Moreover, because the rotation takes place entirely within the hospital setting, most students have little opportunity to appreciate the social and service challenges that patients face when they return to the community. Yet, surprisingly, the development of clerkship rotations in psychiatry that are community based and ambulatory has received scant attention in the academic and clinical literature.

At the University of Florida, under the auspices of the community psychiatry program, medical students have the opportunity to complete their clerkship rotations through participation in three community-based outpatient settings. These initiatives have been designed to provide psychiatric care to underserved populations in urban Jacksonville, and have been specifically modified to provide an educational experience for third-year medical students. Thesites are an ambulatory psychiatric clinic for homeless persons based at a large urban shelter, an integrated primary care community psychiatry outpatient clinic for publicly insured individuals, and an assertive community outreach initiative for persons with mental illness or addiction who live on the streets. The clerkship studentsdivide their clinical timeamong each of these settings during their six-week rotation in psychiatry and also participate in our hospital's consultation-liaison service, which overall amounts to approximately one full day in each clinical site throughout the rotation.

At each site a faculty attending physician who is associated with the community psychiatry program provides direct supervision of the medical students, with a clear focus on fostering competency goals appropriate for a clerkship rotation. The core knowledge and skill sets required for clerkship competency—principles of psychiatric assessment, diagnostics, pharmacology, and psychotherapy—are taught in both traditional (outpatient clinics) and nontraditional (homeless outreach initiative) clinical contexts. Cultivating the most fundamental and clinically applicable psychiatricknowledge and skills required of any practicing physician in the community is an essential goal of this initial exposure to community psychiatry. Moreover, we strongly believe that an essentialelement to providing this meaningful educational experience for students in this community-based clerkship is direct, "hands-on" faculty supervision.

The clerkship rotation also emphasizeseducational objectives that are largely attitudinal. Because each of these clinical initiatives is designed to treat underserved populations in the community, we have an immenselyrich opportunity to address the broader and very real factors that affect the lives of individuals who struggle to manage their mental illnesses in the face of poverty, social isolation, and inequitable access to mental health care. A conscious attempt is made to foster in the student a habit of thinking that is critically reflective on the personal, economic, and social forces that profoundly influence the provision of mental health care to underserved populations.

Since the inception of this clerkship rotation in 2001, more than 150 students have participated. The evaluations of this community-based clerkship rotation by the medical students have been uniformly excellent. However, a number of issues still need to be addressed. Although evaluations of this particular clerkship by the medical students have been uniformly excellent over the course of the past several years, there are still a number of issues that need to be addressed. First, because of the brevity of the rotation, and the ambulatory nature of the clerkship, achieving longitudinal follow-up of patients by students is challenging. Thus students are encouraged to think of informal ways to follow up with patients whom they have assessed—for example, making a brief telephone call or dropping in at the homeless center to check on a person's progress. Second, placing students in an outpatient setting can often be seen as an unwanted intrusion into the therapeutic relationship between provider and patient. Permission is always sought from the patient before a medical student's interaction, and we have had few refusals. Many patients, especially those who frequent the clinic at the homeless center, have later commented that they were glad to "help the students learn about their life on the streets" through the clinical encounter.

In sum, this particular "community psychiatry" clerkship model has worked well at the University of Florida, and we believe it has the potential to be replicated within other academic departments of psychiatry across the nation.