Improving Medical Student Placements in Psychiatry: Review of Literature And A Practical Example

Yasir Hameed, Roger Wesby, Syvarna Wagle, Stephen Agius, Jonathan Hillam & Andrew Tarbuck

Cite this article as: BJMP 2017;10(1):a1008
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The support of medical students during their placement in busy clinical settings is an important topic. Clinicians and other health professionals have a duty to provide teaching to medical students and supporting them to achieve their learning objectives.

This paper reviews the literature on workplace learning and discusses the importance of providing a fruitful and welcoming clinical placement to medical students in Old Age Psychiatry. It then describes a local scheme to improve medical students placement and how the changes introduced in this scheme helped to enhance learning and satisfaction of the medical students.

Although the paper discusses the students placement in Old Age Psychiatry, it is relevant to all other medical and surgical specialities where busy clinicians face many challenges in providing teaching to medical students.

The scheme described in this paper to improve students placement used existing resources and encouraged the input from professionals working within the team (e.g., psychologists, nurses and support workers) to enrich the students placement. Using this multidisciplinary model of teaching and supervision helped to overcome many challenges in providing a positive and useful clinical placement to the medical students.  

Keywords: Clinical, Education envionemnt, Best evidence medical education. Medical students. Psychiatry.


The Royal College of Psychiatrists (RCPsych) launched its five-year Recruitment Strategy in 2011 aiming to achieve a 50% improvement in recruitment to core psychiatry training and a 95% fill rate of posts by the end of the five-year campaign (1). The primary focus of this campaign was on recruiting UK medical graduates.

Two of the Strategy’s main aims were to highlight good practice in undergraduate teaching and to improve the teaching skills of psychiatrists to inspire and influence medical students during their psychiatry curriculum.

The Strategy stressed the importance of good clinical placements in psychiatry and recommended that medical students should ideally be placed only with ‘the best teachers and welcoming teams’ avoiding colleagues who are disillusioned with psychiatry or not happy with their jobs.

It is therefore essential that psychiatrists and other clinicians play an important role to improve the medical students placement in their workplace in order to give the students a positive expereince of this speciality and hopefully promote it as a future career option.


Fourth-year medical students from the University of East Anglia (UEA) spend two months rotating through various mental health services as part of their clinical placement in the Mind Module (also known as Clinical Psychiatry or Module 11).

As part of this rotation, students are placed in Old Age Psychiatry for six days over a two-week period. They shadow clinicians in two community teams, two inpatient wards and the Electro-Convulsive Therapy (ECT) clinic. All of these teams are based at the Julian Hospital in Norwich.

The students are encouraged to talk to patients and carers and perform basic clinical tasks such as mental state examination and risk assessment. Table 1 summarises the learning outcomes for students during their placement.

Table 1- The learning outcomes for students during their Old Age Psychiatry placement
Gain clinical experience of diagnosis and management of mental health problems (including dementia) in older people.
Improve the communication skills with regard to interactions with older people with mental disorders and their carers.
Enhance the student’s understanding of the nature of the multi-disciplinary team (MDT) model in mental health for older people, particularly the social aspect of care and end of life care.

After each rotation, each student is asked to complete a feedback form regarding their placement. This feedback helps the module leads and clinicians to improve the students learning experience.

Before the implementation of our placement improvement project, the students did not feel that they were meeting their learning outcomes. Table 2 summarises the major areas that needed improvement.

Table 2- Areas needed to improve before the implementation of the new placement structure
Poor planning and organisation of the clinical placement.
Inadequate or no information sent before starting the placement.
Lack of a dedicated coordinator to design the placement timetable and allocate students to specific clinicians
Lack of multidisciplinary teaching and hence poor understanding of the various roles of professionals (e.g., memory assessors, community nurses, support workers, etc.).
Students felt that clinicians were too pressured to supervise students. Some students reported that they were sometimes sent off as the staff had been too busy or there insufficient volunteers from clinical staff to take a student.

Student dissatisfaction with clinical placements is not unique to psychiatry. Research has shown that educators and learners face significant challenges when teaching and learning take place in any clinical setting. See Table 3 for a summary.

Table 3- Challenges of teaching in clinical settings (modified from Spencer, 2003)
Limited clinician time allocated to teaching activities.
Administrative duties (dictating letters, writing notes, answering emails).
High number of students allocated to few clinicians.
Difficulty in seeing patients (e.g., patients refusing the presence of a student).
Clinical setting is not ‘teacher friendly’ (overcrowded, too small, noisy and/or lacking privacy to interview and examine patients).
Lack of rewards and recognition for the clinical educators.

One of the biggest challenges of teaching in clinical settings is how to provide a welcoming and supportive learning environment in a busy and time constrained practice. We found that one of the main reasons for clinicians to be reluctant to have students shadowing them is the challenge of providing a dual role of caring and teaching simultaneously.

The placement improvement project

The improved structure of the student's’ placement in Old Age psychiatry was based on the tenet that clinical placements should provide various clinical experiences that include interaction with patients and professionals from various grades in addition to face to face teaching in small groups (3). The authors took over full responsibility for coordinating the students’ placements and liaising with the various supervising clinical teams. This ensured clear leadership and consistency in organising the placement.

The improved placement structure started in October 2015 with the first cohort of medical students coming to their clinical placement after the summer break. Table 4 gives a summary of the changes implemented.

Table 4- Changes to improve the clinical placement in Old Age Psychiatry
Compiling a ‘welcome pack’ and sending it by email to the students before the clinical placement.
A “Meet and Greet” event on the first day of the clinical placement was introduced comprising of several clinicians who operate on a rota basis.
Involvement of all professionals in the MDT (including Staff and Associate Specialists, community and memory nurses, junior doctors and clinical psychologists in addition to consultant psychiatrists).
Introduction of a Balint-style psychotherapy group aiming to facilitate discussion in a safe and containing environment of the emotional impact of patients encountered.
Designing a weekly one-hour teaching session supervised by a senior clinician and facilitated by a trainee psychiatrist.
Each clinician received a formal letter of thanks from the Head of Norwich Medical School, the Module Lead and the Secondary Care Lead certifying their contribution to the education of medical students and thanking them for their work.

The information pack sent to the students before the placement contained information about the hospital environment (location, map, parking, travel arrangements, key codes and useful contact numbers) and a detailed timetable (and email address) of the clinician supervising the student each day during the placement. Also, it included useful information about the mental state examination and the Mental Health Act, information that had been requested previously by medical students.

Sending information before the placement has been shown to be beneficial in students’ electives (4) and this is especially important in psychiatry which can be experienced as less structured than other medical specialities and where students are required to travel to various hospitals and clinics bases. As a result, students felt that they were expected and had a clearer sense of where they should be and who would be supervising or teaching them. Later student feedback reported that these changes had contributed directly to an improved learning experience.

The timetable design ensured that every student would have the chance to experience working in several settings in Old Age Psychiatry, including community, inpatients, ECT and the Memory Clinic. It was also noted that a two-week placement in any psychiatric team could not easily give a student a sense of patient ‘recovery’. It was, therefore, decided that students see a patient who had been discharged from the ward, e.g. with the care coordinator.

The rota of the ‘Meet and Greet’ event on the first day of the placement ensured that the workload is spread among the clinicians and helped sustain the necessary levels of enthusiasm and energy. Previously, this task had repeatedly fallen to just a few clinicians.

The participation of all professionals in the clinical team in supervision and teaching helped the students to better understand the different roles of clinicians within the multidisciplinary team and enriched their learning experience. To achieve this, we attempted to allocate sessions with a clinical psychologist, care coordinators, memory assessment nurses and members of the intensive support team. It also had the bonus of ensuring that the workload of teaching was spread more equally among clinicians.

Attendance at ward rounds and community MDT meetings could be a valuable experience but only if the process is explained, and – in the ward round – the student is briefed on the clinical history and background of the patients. For these reasons, supervising clinicians were reminded to give this information to the students attending such meetings.

The weekly teaching sessions provided an opportunity for the students to present case histories of patients they had seen and to discuss their management. Clinicians could also give a formal didactic teaching on a specific topic, for example, mental state assessment or risk assessment in psychiatry.

The letters of thanks to the participating clinicians served as an added benefit (in addition to the satisfaction of teaching others) to sustain their motivation and reward them for their contribution to the teaching of medical students. The psychiatric trainees used the letter to demonstrate their skills in teaching in their portfolio.

Benefits of the new placement structure

Helping students to feel supported before, during and even after their placements was a high priority in this project. Research has shown that learners rank the need for support and guidance in workplace environments as high and it is an essential requirement for a successful learning experience (5). This extra support is particularly crucial in psychiatry which is perceived by many students to be difficult and challenging (6).

The support provided to the students in the improved structure was in the form of having the contact details of the rota coordinators, their supervising clinicians, the administration team (medical secretaries, site manager for parking permits) and some other useful numbers for various locations and clinics.

While improving the organisation of the placement, changes were aimed to reduce the commitment of teaching and supervision for clinicians and spread it more equally among the members of the team.

Students reported that they found home visits during the placement the most useful part of their placement and the most interesting. This is an invaluable experience with the student having a significant amount of time in a one to one interaction with a clinician (including during the travel from one location to another) and then observing the clinician ‘in action’ with patients at home. This experience highlights the role of ‘professional socialisation’ (7) that is considered by educators as a significant process in the development of a sense of a shared professional identity and responsibility in both the clinician and the learner.

Furthermore, using non-medical professionals to supervise and teach students has been valued by students (8). It enriched the clinical placement with the concept of (Inter-Professional Learning) which is an active learning from and with professionals from other disciplines allied to medicine. This style of education has been shown to improve students’ communication with professionals from different disciplines and to have a better understanding of the nature of the multidisciplinary teamwork and the roles of each member of the team (9).

While improving the organisation of the placement, changes were aimed to reduce the commitment of teaching and supervision for clinicians and spread it more equally among the members of the team.

Balint groups and improving student placements in psychiatry

Balint groups were pioneered by the Hungarian psychoanalyst Michael Balint who introduced this model in the late 1950s after running seminars for general practitioners in the UK with his wife, Enid. (10)

Balint recognised the intense emotions that affect the doctor and the patient and encouraged clinicians to talk about these feelings in groups, which later came to be known as Balint groups.

Research has shown that Balint groups for medical students can increase the students’ empathy towards patients with chronic mental illness and improve their ability to cope with complex clinical situations (11). It also helps them to engage in reflection about their professional growth and to develop their identity as future doctors (12). Most importantly, this psychotherapeutic approach it allows them to reach a deeper understanding of the emotional impact of their patients (13). It was felt that the students would benefit from this model to help with the various emotions evoked by dealing with patients they would encounter in Old Age Psychiatry, in particular, dementia.

The student feedback was very positive for the Balint group. One student commented. It is inevitable to have experiences with patients that leave you with a feeling, whether that be positive or negative. To be able to look back at those times, talk them through, be listened to and have others reflect things back that you may not necessarily have realised yourself, is invaluable’.

Patient and carer involvement in clinical education

Clinical education in the workplace has always depended on patients and carers in its design and delivery. Students value seeing patients and learning from their experiences. However, the evidence suggests that patients are not routinely involved in the design of the curriculum or clinical placements despite calls to actively engage them in teaching and training (14).

Students were given the opportunity to learn from patients and carers through regular and supervised contact with them. They also attended a workshop on dementia and viewed a DVD showing the experiences of a woman with dementia and depicting how the world might be seen from her perspective. Feedback from students was very positive for these opportunities.

Medical students placement and Electro-Convulsive Therapy (ECT)

Students are allocated to spend one day in ECT clinic during their two-week placement in Old Age Psychiatry. Research has shown that many medical students have negative attitudes and unjustified reservations about ECT and its therapeutic applications (15). However, these views can change with education about this therapy during clinical placements and encouragement of the students to talk to patients and read about its indications and effectiveness in people with severe mental illness (16). Seeing the procedure first hand would, therefore, help the student gain confidence to challenge the stigma attached to ECT and to explain this treatment to their future patients.

Feedback from the students following the implementation of the placement improvement project

The feedback from medical students and clinicians was very positive. The students enjoyed their placements and felt that they gained useful knowledge and skills. Above all, they felt welcomed in the clinical settings and settled very nicely into the teams.

Figures 1 and two summarise some comments from the medical students following the placement. This feedback was collected by Norwich Medical School as part of the regular monitoring of clinical placement for medical students.

Figures 1 and 2: Feedback from students after the implementation of the changes to the clinical placement:

‘Best part of placement. Doctors were all happy to have us and teach. It was well organised, I felt that we were welcomed and always expected. It was varied and generally useful to my learning needs’.
Student ID 69. End of Module 11 feedback.


‘This was one of the best placements in psychiatry, each doctor was very helpful and especially keen on teaching. It was really good to not only see the patients on the ward but so helpful to go on home visits to see assessments in patients own home. Really enjoyed this placement’.
Student ID 95.


There were some challenges in the implementation of this improved model. First is not always easy to recruit non-medical members of the clinical teams to take students. There are some reasons for this including lack of confidence or experience in teaching, a belief that it is “not their role”, or concern about the increasing demands on their time. Others already had students in their discipline. This was addressed by briefing the professionals about what the students need to achieve at the end of the placement and encouraging them to be involved in the supervision. The introduction of nursing revalidation in April 2016 may help more nurses to get involved. (17)

Conclusions and recommendations

This paper describes a clinical placement improvement project for medical students in Old Age Psychiatry. The changes focused on the enhancement of organisation, supervision and teaching.

Our improvement project is ongoing, and there are areas needing further improvement, for example, more active involvement of patients and carers in the teaching and learning of medical students is necessary. It is planned to achieve this by inviting patients and carers to tell their personal stories to the students in a small group.

Organisers of students’ placement in secondary or primary care need a systematic approach to filling allocation slots to ensure that all students receive a similar and broad exposure to their speciality. It can be dispiriting and stressful to ask for volunteers constantly. They need to have good relationships with their clinical colleagues of all disciplines, and to be willing and assertive enough to go around and ask colleagues in person rather than sending email requests.

Psychiatric educators have a significant role to play in the improvement of clinical placements for students as this will hopefully contribute to improving recruitment to this medical speciality that is undergoing a recruitment crisis. Research has shown that there is a positive correlation between the length and quality of clinical placement and the likelihood of choosing psychiatry as a future career. (18)

We would like to thank Professor Chris Fox (Clinical Professor of Psychiatry and Senior Honorary Lecturer, Norwich Medical School) for revising the manuscript and providing feedback on improving it. We also would also like to thank Professor Richard Holland (Professor of Public Health Medicine and Honorary Professorial Fellow, Norwich Medical School) and Dr Julian Beezhold (Consultant Psychiatrist and Honorary Senior Lecturer, Norwich Medical School) for their support in the design and implementation of the improved placement structure described here. Finally, we would like to thanks the numerous professionals from various grades and job roles who supported these changes to improve the students’ placement in Old Age Psychiatry.
Competing Interests
None declared
Author Details
YASIR HAMEED (MRCPsych, PgDip Clin Edu, FHEA), Honorary Senior Lecturer (Norwich Medical School, University of East Anglia), Consultant in Adult and Older Adult Psychiatry. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE. ROGER WESBY (MRCPsych), Consultant in Old Age Psychiatry. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE. SUVARNA WAGLE (MRCPsych), Consultant in Old Age Psychiatry. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE. ANDREW TARBUCK, (BM BCh, MA, FRCPsych), Consultant in Old Age Psychiatry. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE. STEPHEN AGIUS (MD), Associate Specialist. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE. JONATHAN HILLAM (MRCPsych), Consultant in Old Age Psychiatry. Norfolk and Suffolk NHS Foundation Trust. Hellesdon Hospital. Norwich. NR6 5BE.
CORRESPONDENCE: YASIR HAMEED, Norfolk and Suffolk NHS Foundation Trust, Hellesdon Hospital, Norwich NR6 5BE.


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