Psychiatry Clerkships During COVID-19: How Medical Schools Are Responding

An announcement from the Association of American Medical Colleges (AAMC) regarding medical student clinical rotations during the COVID-19 pandemic effectively halted medical student education on March 17th. The AAMC urged medical schools to suspend all clinical rotations for students until at least April 14th, 2020.¹ The AAMC gave broad guidelines for medical students wishing to engage in direct patient care in the interim, which instructed medical schools to see all medical student interaction in the clinical realm as voluntary. An updated guideline was published on April 14th which added some specifications regarding clinical students returning to direct patient care to fulfill core requirements.² No definitive timeline was given for when students should return, rather a list of recommendations for how to reintegrate students in a meaningful manner that would also fulfill the school’s graduation requirements was laid out.

It is important to note that with the AAMC’s updated guidelines, each individual school will have to determine where, when, and how students may reengage in direct patient contact. This restart will undoubtedly vary widely from institution to institution as the guidelines encourage schools to consider the impact COVID-19 is having on their institution and what aspects of the health care system are currently functioning at each student’s institution. Still, many third-year medical students are currently unable to engage in their required core clerkships and have already lost one month of clinical experience.

A psychiatry rotation is a core clerkship at every medical school. When deciding how to implement a revised format of the psychiatry clerkship, medical schools have a wide range of options. The psychiatry clerkship does not exist in a vacuum and will need to be coordinated with the other required clerkships at a medical school. While it is still too early to know when clinical students will be allowed to have direct patient contact, many clerkship directors and medical educators are working on how to respond to this situation. Some have already begun participating in telemedicine visits, while others will be slowly re-introduced to clinical sites in the coming months.

Student experience
To get an initial understanding of how different medical schools are responding to this situation, a few medical students in Michigan and Ohio were contacted. The students explained the innovative ways their medical schools are handling the psychiatry clerkship in light of COVID-19.

Wayne State University School of Medicine
For third-year students at Wayne State University School of Medicine (WSUSOM) in Detroit, the rise of COVID-19 in Michigan coincided with the final month of the 2019-2020 academic year. Approximately 25 students were scheduled to end their year with the core psychiatry rotation from March 19 to April 10. Instead of canceling the rotation, faculty and leadership adapted quickly to develop a remote curriculum that would expose students as much as possible to the field of psychiatry.

According to students who took the course, educational materials included simulated online cases and videos, for which they were asked to document mental status examinations, differential diagnoses, and treatment plans. They then discussed these cases in small groups over Zoom with the clerkship director. For one early assignment, students were asked to rethink a real case seen on their neurology rotation from a psychiatric perspective. Two or three times per week, the entire cohort met on Zoom to clarify assignments and watch lectures. These included talks by subspecialty faculty, a trauma psychologist, and the department’s Chief Resident, who also led a “choose your own adventure” decision-making case with students. Importantly, students discussed COVID-19’s impact on mental health. They wrote reflections on how a psychiatric diagnosis might affect an individual’s response to the crisis and learned what psychiatry residents were doing to support their colleagues in other fields. As all learning was remote, students will be required to participate in two weeks of clinical psychiatry experiences at some point during their fourth year.

Fourth-year electives are also being adapted at WSUSOM. In addition to didactics and team meetings, the Child and Adolescent Psychiatry elective has incorporated telemedicine in a significant way, encouraging student participation in follow-up visits conducted over Zoom with fellows. The structure of future rotations, including the core clerkship for incoming third-year students in July, will continue to evolve as the situation permits.

Michigan State University College of Osteopathic Medicine
At Michigan State University College of Osteopathic Medicine (MSUCOM), all core clerkship rotations, including the core psychiatry rotation, have been completely halted. Instead of continuing core rotations in an alternate format, third-year students completed an online, case-based internal medicine rotation last month. This online rotation will replace an elective rotation that would normally be completed in a student’s fourth year. Students will likely have fewer opportunities for psychiatry electives as fourth-year elective time is shortened to 28 weeks from the originally planned 32 weeks. Students who were on a psychiatry core rotation that was originally scheduled before COVID-19, will now complete the rotation in their fourth year. MSUCOM has since created online rotations for every core specialty-including psychiatry. They are anticipated to be mostly online, utilizing online case-based learning platforms like Desire2Learn and Aquifer. Specialty-specific Zoom meetings will also be utilized to provide students face-to-face contact with clinical instructions. Specifically, the psychiatry online rotation will include observed interviews as well as mental status exams and suicide risk evaluations.

Some hospitals plan to utilize telehealth; however, not all hospitals in the MSU Statewide Campus System can provide that opportunity. As of the writing of this article, there are no plans to make participating in telehealth a requirement of clerkships. Meanwhile, second-year students wait to see what will happen to them. Prometric testing centers, where the USMLE Step 1 and COMLEX exams are taken, have closed around the country until May 1. With MSUCOM scheduling every student to take board exams in the months of May and June, many students are anxious and concerned about further delays in the reopening of Prometric testing centers.

Ohio State University College of Medicine
Third-year clerkships at The Ohio State University College of Medicine (OSUCOM) follow a unique schedule with clinical rotations arranged into 16-week “rings” and multiple 2-4 week rotations in various specialties and clinical experiences. Cinical rotations were suspended on March 14th, leaving some medical students with no psychiatry experience. To complete the academic year and advance third-year medical students as scheduled, various online alternatives were created depending on specialty.

To fulfill psychiatry requirements, students completed case-based online learning, OSUCOM specific learning modules on topics ranging from firearm safety to ECT, and readings from the DSM-V. Weekly small group sessions continued in virtual format. In addition, a minimum of 2 weeks of clinical psychiatry experiences will be required, which may be fulfilled upon return to the clinical environment through fourth-year elective rotations if necessary. Students were given the opportunity to complete the NBME Shelf exam as scheduled or to defer the exam until after completing additional clinical experiences.

At this time, both third- and fourth-year OSUCOM students are anticipated to return to the clinical environment in June, which would be a delayed start by 1 month. Students are encouraged to use the month of May to complete an online-based elective or study for board exams. Upon return, both rising third- and fourth-year medical students are anticipated to work at full capacity with minimal adjustments made to student roles.

Conclusion
Medical students are among the people fortunate enough to be able to continue working from home. Video conferences with educators and peers, combined with multiple online platforms for case-based exercises and learning modules seem to be how most medical schools are continuing education. Even though telepsychiatry is on the rise, there are still barriers to having medical students take part in these visits now to fulfill psychiatry clerkship requirements.

While traditional methods of completing a core psychiatry clerkship, such as an inpatient or consultation-liaison psychiatry rotation, are almost impossible to complete on a fully virtual basis, the steps that medical schools are taking to keep students engaged should be applauded. The combination of extended stay-at-home orders, fear of the virus itself, and economic instability that is already starting to become evident has the potential to cause wide reaching mental health challenges in the very near future. Continuing psychiatric training for medical students at this time is essential, especially since this event will likely only increase the demand for psychiatric services.

Disclosures:

Mr Hanslits is an MD candidate, University of Michigan Medical school; Dr Cenker is an MD candidate, The Ohio State University College of Medicine; Mr Mancine is a DO candidate, Michigan State University College of Osteopathic Medicine; and Ms Utter is an MD candidate, Wayne State University School of Medicine. They report no conflict of interest concerning the subject matter of this article.

Acknowledgments-The authors thank Michelle Riba, MD, MS, and David Belmonte, MD, at the University of Michigan Medical School; Richard Balon, MD, at Wayne State University School of Medicine; Meera Menon, MD, and Julie Niedermier, MD, at The Ohio State University College of Medicine; and Jed Magen, DO, MS, at Michigan State University College of Osteopathic Medicine.

References:

1. Association of American Medical Colleges. Important Guidance for Medical Students on Clinical Rotations During the Coronavirus (COVID-19) Outbreak. March 17, 2020. 
2. Whelan A, Prescott J, Young G, Catanese VM, McKinney R. Guidance on Medical Students’ Participation in Direct Patient Contact Activities. Updated Guidance for Medical Students’ Participation in Direct Patient Care During the Coronavirus (COVID-19) Outbreak. April 14, 2020.