Guest blog: Dr. Niall Byrne reflects on his Intern year

The guest blogs from four University of Limerick graduates over the past few weeks have provided fascinating insights into the different stages of training to become a Psychiatrist. 

Dr. Diarmuid Boyle focused primarily on starting off in Psychiatry and the Basic Specialist (BST) years:

https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-dr-diarmuid-boyle-on-making.html

Dr. Noreen Moloney reflected on those heady days of Higher Specialist Training (HST):

https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-dr-noreen-moloney-on-making.html

Then along came Dr. Kevin Lally, who has finished BST and a year as Psychiatry Clinical Tutor in UL and he had a trilogy of blogs on:

Telemedicine and Telepsychiatry: https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-part-1-of-dr-kevin-lally.html

and then two blogs on medical education during the COVID-19 pandemic: 

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html

and

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-3-of-dr-kevin-lally.html

Then last week Dr. Frank McKenna, who has also completed BST and a year as Psychiatry Clinical Tutor in UL, reflected on teaching, research and the wide variety of career options within Psychiatry:

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-dr-frank-mckenna-year-in.html

This week I have great pleasure in welcoming Dr. Niall Byrne, yet another extremely bright, energetic and talented graduate of UL who is embarking on a career in Psychiatry while also cultivating a variety of other interests. And this week we are going back to the very beginning of postgraduate training, with Niall's very thoughtful and useful reflections on his Intern year and his hopes and plans for the future. Niall has also included two beautiful works of art to accompany his text. 

So thank you Niall and it's over to you...

Dr. Niall Byrne - biography

I am to commence the Psychiatry Basic Specialist Training (BST) sceheme in Dublin in  July, after completing the academic internship at Galway University Hospital. I graduated from the Graduate Entry Medicine programme at the University of Limerick in 2019. I am interested in innovation in medicine and research and hope to specialise in Child and Adolescent Psychiatry.  Beyond this I am interested in art and videomaking and I have recently made comedy medical voice over videos which has been circulated among the medical community across the country: https://www.instagram.com/medhumer/?hl=en

Reflections

As I reflect upon the past 12 months, I feel a sense of achievement having overcome the steepest learning curve of my life, but I am apprehensive for changeover. I was fortunate enough to achieve the only academic internship post to include a psychiatry rotation, which was based entirely in Galway University Hospital (GUH). My first three months were in general adult psychiatry and I was based mainly in the acute Mental Health Unit (MHU), which is an impressive two-storied newly built facility with over 50 in-patient beds.

I was split between two consultants and worked on the community mental health (CMH) team under Dr Brian Hallahan, attending weekly multidisciplinary team meetings as well as outpatient clinics. The CMH multi-disciplinary team understood the patient’s life beyond their diagnosis, something which is not afforded the same amount of discussion in other specialties, which is essential to that patient’s management. Moreover, I found out-patient clinics a particularly helpful means in developing my clinical acumen. As my confidence and knowledge base developed, I was seeing patients alone and making decisions and changes to patient’s management.

On Professor Colm McDonald’s team, we looked after the acute adult in-patients. I was given the opportunity to present case discussions and do full medication reviews as well as attend rounds and making adjustments to inpatient’s medical management where necessary. My perceptions of psychiatry practice prior to working quickly transitioned into reality and I was relieved by how much it lived up to my expectations. On one occasion I presented a complex case of refractory paranoid schizophrenia during the weekly case presentations, and together we devised a treatment plan. This was a rewarding experience. As a psychiatry intern, you get as much out of it as you invest. You can have minimal responsibility, or you can really get enthralled and maximize your learning. I tried to gain as much as possible as I was strongly leaning towards a career in this field for a number of years.

Rainy Day by Phan Tru Trang

The one major setback to commencing the intern year on a psychiatry rotation is having to do medical call with minimal exposure to acute medicine during the day job. When starting off on my extended days even navigating around the main hospital was challenging. On one of my first nights the medical registrar questioned why a psychiatry intern was doing medical call, when we both had to manage a deteriorating patient on one of the wards. However, he later apologized for the comment and admitted that he was stressed because it was his first day in GUH. I quickly learned that if people are difficult there is generally an underlying reason and you just have to give them the benefit of the doubt and not let it affect your own performance. Although if it is something more persistent or it hinders your patient’s care then it should be dealt with appropriately to avoid conflict, burnout or mismanagement.

After psychiatry I rotated onto vascular and general surgery. I enjoyed the level of responsibility being on such a small team. Surprisingly, there were several opportunities to develop my psychiatry skills. One episode that stands out was a middle-aged female patient who was admitted with painless jaundice. She needed a CT and my registrar informed me that she was 'too nervous' to go through with the scan. I insisted on carrying out a brief psychiatric assessment which revealed a long-standing history of generalized anxiety with progressive loss of function that was refractory to treatment. She also suffered a number of traumatic life events that she had not disclosed previously. I arranged for a liaison psychiatry review and she was commenced on treatment and would be followed up in the community. I taught her some basic mindfulness and prescribed a stat dose of alprazolam. She completed her scan and was discharged. She said this experience had saved her life and would make a great change going forward; she was so grateful that she gifted me with an angel statue during a follow up appointment.

My current rotation is in respiratory medicine, which brings with it a heavy workload, but the team were particularly easy to get on with and made the experience much more enjoyable. I found myself enjoying medicine a lot more than I anticipated and was particularly fond of acute management while on-call. Eventually I was making medical decisions on-call and during the daytime with confidence and my procedural and management skills developed rapidly.

When the COVID pandemic emerged, my team was at the forefront. However, I remained the only intern on the wards which brought with it additional responsibility. The respiratory inpatients at this time were highly specialized cases, mainly patients with cancer and cystic fibrosis. For a long period of time it was just me, the consultant and an SHO. I was arranging family meetings and breaking bad news to patients and families, which although was difficult, it was a great learning opportunity. As an intern we have the privilege of being able to re-visit patients who may have received bad news on a round or who don’t quite understand their management regimen, etc. Something I carry into my career was said to me by a dear friend of mine, who told me that when her mother, who is a nurse and suffered from acute leukaemia, said that sometimes all she needed was for someone that she can vent with. I would always take the time to see patients later on in the day and give them the time they needed, to explain or to simply lend an ear from person to person. In medicine there’s a tendency to launch towards a psychiatry referral for someone going through an acute adjustment reaction or who has psychosocial stressors without even enquiring about a psychiatric illness. I think offering these patients a psychiatry referral is insulting to both the patient, and the speciality, and it is a message I always stress, to avoid this from happening. A patient should not be labelled as requiring psychiatry input for experiencing human emotion.

Every intern will encounter a trauma or case that will affect them. Our resilience can only be stretched so far. GUH’s cohort of interns and staff in general are kind and willing to help one another and this sense of comradery softens the blow of the intensity of the intern role, a role which is diverse, challenging but rewarding. I am happy to say that I thoroughly enjoyed my job and found the year rewarding and eye opening.

I will commence the Psychiatry BST as an SHO as part of the UCD deanery in mid-July. I have mixed feelings as I have fallen in love with Galway and GUH and will miss it and many people dearly. At the same I am excited to begin my training as a psychiatrist, and I am confident that this is the right path for me having reflected upon my experiences. My goals are to bring about change for patients and for colleagues. As I specialize in this field, I will dedicate time to quality assurance, research and education. Most importantly I will carry the message to be kind to your colleagues and to always be an advocate for your patients.

After the Rain by Phan Tru Trang

Guest blog: Dr. Frank McKenna - A Year in Time: Reflection on a year as Clinical Tutor

This week I am delighted to welcome yet another graduate of the University of Limerick Medical School as a guest blogger. Dr. Frank McKenna has just completed a year as Clinical Tutor in Psychiatry with UL. During that year, Frank has become immersed in the worlds of medical education and research and his students have been lucky to have had such a talented, wise and dedicated teacher and guide. Frank has provided a very modest biography (see below) so, along with his wide range of accomplishments in his first few years in psychiatry, I must add that he is not just 'a writer of fiction' but an award winning author. For artistic accompaniment this week, Frank has suggested two of his favourites - Limerick artist Annemarie Bourke and Gibraltarian artist Christian Hook.

Frank's biography: 

Frank McKenna completed psychiatry BST in 2019 and will commence HST this July. He has spent the intervening time as a Clinical Tutor in Psychiatry with the University of Limerick (UL). A former Business and Information Systems graduate who worked in both IT and retail management, he completed Graduate Entry Medicine in UL in 2015. He has varied interests within psychiatry including Sports Psychiatry and Narrative Psychiatry. He is a writer of fiction, and avails of any opportunity to speak to a crowd. 

Evening on the Shannon (Annemarie Bourke)

George's Head, Kilkee (Annemarie Bourke)

A Year in Time: Reflection on a year as Clinical Tutor

Affect. I described it routinely. Congruent and resonant, appropriate and reactive, perhaps incongruent and blunted, or inappropriate and flattened, or some other combination of a limited collection of descriptors.

The lecture notes I inherited likened affect to the weather, in contrast to mood being the climate. The same simile was on the same slides when I went through my psychiatry rotation at the University of Limerick (UL) in 2015. I wasn’t sure about it then and I’m not sure about it now. But the night before I would first deliver this particular lecture – MSE: Mood, Affect and Risk – after a little thought, I came to enough clarity to think “I’ll run with it.”

 

Foxes Bow, Limerick (Annemarie Bourke)

From Clare to Here (Annemarie Bourke)

Climate and mood pervade in the background. They influence the likelihood of what will be visibly evident at any given time: the weather, or the affect.

By 11am the following morning weather and climate were out the window, where they bloody well ought to be. Eventually inevitable, this reaction was catalysed by the twenty-eight gazes that materialised incremental layers of glaze with each of my attempts to clarify what was becoming increasingly abstract in my own head.

There is a lot of focus in medical education theory on the value of feedback. I found that the best feedback is not sought, but evident in the students’ engagement and in the looks on their faces. This was my principal guiding force: Are they engaged?

I resorted to being less clever than my predecessors.

We ask two questions about affect:

(1)   How reactive (or resonant) is it?

(2)   How congruent is it with the patient’s mood?

The twenty-eight pleasant nods I received allowed me to think this had done the trick. The students’ first written case presentations at the midway point of their 6-week psychiatry rotation illustrated that the trick certainly had not been done. Patients’ affects were all manner of verbs and adjectives: “happy”, “crying”, “tense”, “laughing”. Some were even “good” or “bad.”

I had a few tries at this. In UL we teach the same course 5 times in the academic year as students rotate through the psychiatry placement. In the end I think I had it down, and this came with realising that, in the Mental State Exam, we are not asking “what is the patient’s affect?” The question we ask is “how good is their affect?” That is, how well does their affect represent their mood? Towards the end of the year, reactive and congruent affects began to stream in, and all was right in the academic world.

Shodo Series 2019 (Christian Hook)

The Ambush (Christian Hook)

In July I will start my first post as a Senior Registrar (SR), but for the last (almost) eleven months I have been outside of clinical training, working fulltime for UL, teaching psychiatry to medical students.

I applied for this job for many reasons, but mainly I wanted more teaching experience and I wanted to get a research boost prior to starting HST.

Teaching hours were not as many as I expected – guest lecturers deliver about half, leaving the other half to share between Kevin (my fellow tutor) and myself. Initially this was a tad disappointing. I was chomping at the bit to strut my stuff, impart knowledge to, and open the minds of, roomfuls of focused final years. I had notions. It did not take long to realise the teaching hours I had were plenty, even ideal; easily enough to maximise teaching skills, time to prepare well, time to ponder how best to get the content across and afterwards to reflect on to how to do better.

That is not to say that time is there to be spent staring out the window, thinking the long thoughts of youth (not quite applicable in my case anyway, I’m afraid). The tutors are there to ensure the course runs well. Kevin and I had the advantage of having both gone through the course as students. The problem-based philosophy in particular came naturally to us, but still, time fills up. Scheduling lectures, liaising with lecturers (mainly consultants and SRs), filling in at teaching when things crop up unexpectedly, takes a chunk every now and then. Assessment of students is a continual process – monitoring engagement, assessing written assignments, delivering feedback, identifying the rare struggler, preparing end of year exams, and not infrequently addressing students personal or interpersonal issues.

This year coughed up the particular challenge of creating a new online assessment to replace the clinical exam. The aim was, in some way, to confirm that this year’s graduates understand the subtleties of a psychiatric interview – but there is much more on that in my colleague’s previous posts:

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html

https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-3-of-dr-kevin-lally.html

A year free of clinical responsibilities is a huge opportunity, not just to boost research output but also to improve research skills. The former, for me, despite a lot of work, has been hindered by Covid-19, but I am hoping foundations are laid to produce results in the months ahead. My research skills, on the other hand, have vastly developed. Planning projects, proposing to supervisors, reviewing literature, discussing aims and methodologies, collecting data, analysing data, writing papers – there is probably no substitute for going through these processes, and this year I was able to supplement this work by availing of relevant and useful tutorials and short courses available to University staff. I am a latent powerhouse of research.

More than anything else, I have enjoyed the year. Whatever about its place on my CV, it has allowed me to develop as a teacher, into having a clue and having an opinion when it comes to research. It has made me continually question my knowledge, and thus has deepened and broadened my understanding of psychiatry. It also removed me from the blinkered path from intern to consultant and broadened the scope of where I think my career could go.

HST is waiting. I have not seen a patient in a year so in the first days there may be some toe dipping. Soon enough I will be sailing again, and a year as UL Clinical Tutor in Psychiatry has given me a greater understanding of the vastness of the ocean ahead.

Origins (Christian Hook)

La Nostalgia de Londres (Christian Hook)

Guest blog: part 3 of the Dr. Kevin Lally trilogy; lessons learned from online teaching

Lessons Learned from Online Teaching

Following on from Dr. Kevin Lally's excellent guest blogs from the last two weeks, on telemedicine and telepsychiatry https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-part-1-of-dr-kevin-lally.html and on medical education during COVID-19  https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html, Kevin finishes his trilogy of blogs this week. 

As mentioned before, Kevin can be followed on Twitter: @kevinly

Next week we will have a guest piece from Dr. Frank McKenna, reflecting on his year spent as a Clinical Tutor with the University of Limerick.

Should you the readers have any suggestions for additional blog pieces, or indeed submissions of your own, please contact me via the comments section below or directly via email hpoconnell@yahoo.ie 

So it's many thanks and over to Kevin again - for this week he has suggested some artistic depictions of the Greek allegory about Cupid and Psyche, the latter of whom obviously makes a major contribution to the etymology of 'Psychiatry'.

From the previous blog post available here https://psychiatry7trainingtips.blogspot.com/2020/06/guest-blog-part-2-of-dr-kevin-lally.html  you have heard how the University of Limerick (UL) Graduate Entry Medical school adapted its Psychiatry module under exigent circumstances to the challenges of COVID-19.

This article will address some approaches that can be considered in the planning stages between courses to help ameliorate the restrictions. Firstly, we can establish that it is very difficult to forecast when COVID-19 restrictions will lift or predict if or when we will return to pre-COVID circumstances. Thus, this article is written in the context of much uncertainty and ambiguity, not very much like clinical practice.

There are at least four areas that need careful consideration

• ·         Clinical experience and patient encounters

• ·         Simulated patients

• ·         Reduction in opportunity to complete Workplace-Based Assessments (WPBA)

• ·         Student Assessment

Clinical experience and patient encounters

Clinical exposure to patients is an absolute requirement for medical student development and this is no less the case in psychiatry. Meeting patients in outpatient departments, community scenarios and in-patient wards really adds to the student learning experience and refines important skills. As much as possible, these need to be conserved going forward, with social distancing and the use of masks or otherwise as per national guidelines. A useful approach will likely be telemedicine which is discussed in another blog post <here insert hyperlink>. When Doctors and preceptors are conducting patient assessments under teleconference by phone or by video, students should be encouraged to join in. A really meaningful and practical approach would be to have a student join their Consultant by teleconference for a brief case-based discussion followed by the patient assessment and finally finished with another discussion. A very busy and stretched clinical service might still be able to do this at least once a day for a student.

Another critical aspect of psychiatry placement is integration within the Multidisciplinary Team environment (MDT), getting to know the different professions and roles within a psychiatry MDT and experiencing how meetings are conducted. Again, students should be encouraged to join MDT discussions by remote conference or attend in a socially distanced manner if the environment has capacity.

An extension to this might include asking students to contribute to the “Social Support Call Service” that was recently launched by the HSE Mental Health service. This initiative is described by the HSE as “a non-clinical service aimed at maintaining a link with Services Users who are isolated through the current restrictions and it will offer them an opportunity to talk to a staff member of the HSE.” 

Simulated Patients

While access to patients in a clinical setting is ideal there will be scenarios and situations where this not be possible. Thus, simulated patient (SP) encounters in high fidelity environments is likely the next best step. How this might work would be an actor, whether in socially distanced environment or videoconference (VC) would play the role of a patient and students could practice their clinical skills here. Perhaps a low fidelity approach would have staff members play the role of a SP and perhaps below that again might be students playing the roles themselves.  As you might imagine these approaches will differ in terms of cost and convenience.

A similar but distinct approach would be the use of virtual patients.  This includes using simulated patient-doctor interactions as videos (or merely text) and implementing them into a virtual clinical decision-making environment. While this is an exciting area of current research and investigation it is both complex and complicated and requires significant time and resources to make models. St George’s Medical School has a particularly developed set of cases for this. http://www.elu.london/virtual-patients-2/

Reduced Opportunity

Curricula and syllabi devised for F2F training environments pre-pandemic will need to be adapted for COVID-19 restrictions and compromise is inevitable. Curricula will need to be revised, perhaps temporarily to match the reality of the current situation. The Royal College of Psychiatrists in the UK has already made steps to address changing the required workplace based assessments that need to be completed during rotations to account for these changes https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/covid-19-and-psychiatric-training. The College of Psychiatrists in Ireland has alerted trainees that they may face difficulties in acquiring certain workplace-based assessments, but any deficits will likely be required to be made up in later placements. 

Assessment

Assessment and evaluation are critical components of Medical Education both at undergraduate and postgraduate levels. In a previous blogpost <insert hyperlink> we described how final year medical exams were brought forwards and examinations took place online. While MCQ style questions easily transition to digital formats clinical style examinations were more difficult to adapt to remote video conferencing. Another factor was appropriate invigilation and proctoring. In the case of UL GEMS online proctoring software was brought in that would allow a set of invigilators to monitor the screens of students completing examinations and monitor the students themselves via their webcam.

In terms of clinical examinations, the mighty OSCE was replaced by a variety of clinical decision-making examinations and data-interpreting examinations. The OSCE is seen as the gold-standard for assessing clinical skills however due to the level of COVID-19 restrictions and the limits of time VC OSCEs were not feasible for this cohort. In principle they would work well, with a simulated patient, an examiner and a candidate all joining the same video conference to perform a clinical exam, most likely an information giving style station or a history as opposed to a physical examination (for perhaps obvious reasons).  Here is a link to an example of a Clinical Reasoning Exam: https://forms.gle/wt2xswC5qFABLJzC6.

Prior to COVID-19 UL GEMS ran three 10-minute OSCE stations for 125 students requiring 30-40 simulated patients (actors) and 30-40 examiners (Consultant Psychiatrists or Senior Trainees) taking place over about 8 hours in a large conference area (local hotel). The UL GEMS admin and examination team have been conducting these styles of OSCEs for years and have mastered the careful balancing act of logistics, organisation and planning to pull this off. Unfortunately, it was not feasible to convert this type of exam to a VC for this volume of people. So as GEMS graduated 125 students in May 2020 they join a record numbers of doctors working as interns in Ireland https://www.imt.ie/news/record-1800-interns-employed-health-service-01-05-2020/

Online OSCEs have reportedly worked well in post-graduate courses like the M.Sc in Obstetrics and Gynaecology offered by UCC (https://www.ucc.ie/en/ckx12/) so it is probably a matter of scale rather than concept.

Both the College of Psychiatrists and the Royal College of Psychiatrists have cancelled or deferred their written examinations and their clinical examinations for summer 2020. Both Colleges are investigating alternative avenues to assess their trainees and will likely settle on social distanced physical examinations rather than online examinations, but this remains to be finalised.

In summary, COVID-19 is offering many challenges to the operation of training but there are many creative approaches to compensate. This time next year we will likely have a much more robust system for addressing restrictions with more embedded online learning and training systems. 

Guest blog: part 2 of the Dr. Kevin Lally trilogy; medical education during a global pandemic

Thanks to the high quality of recent guest blogs and the interest and support of colleagues, this blog has now had over 2,000 reads with the readership coming from 18 countries and spread over all continents (apart from Antarctica, but I'm hoping to see readership taking off there soon).

Dr. Kevin Lally started his trilogy last week with a very timely and pandemic-relevant piece on telemedicine and telepsychiatry:

https://psychiatry7trainingtips.blogspot.com/2020/05/guest-blog-part-1-of-dr-kevin-lally.html

Kevin has followed up last week's contribution with another belter of a blog this week, where he combines his experience as Clinical Tutor with the University of Limerick during this strangest of academic years with a really lively and thorough review of issues relating to designing and delivering medical education during COVID-19 and beyond.

For added colour this week, I have included some images from Danish illustrator Kay Nielsen (1886-1957), of whom Kevin is a fan.

So it's over to Kevin again...

Teaching Psychiatry during 

a Global Pandemic

The COVID-19 pandemic has brought many challenges to the delivery of medical education both at an undergraduate and post-graduate level. Universities and Post-Graduate training bodies have had to act quickly and creatively to address these challenges. Perhaps an unexpected outcome was the opportunity to assess both what we teach and how we deliver it as we grapple with what is essential in times of global crisis.

Medical school - Who cares and why?

One’s first impression, especially if we look at the severity of the situation in Italy in March 2020 would be to postpone everything relating to medical education. At home and abroad medical services were being prepared for a surge of presentations that could tax the most robust health systems and potentially overload those that are chronically under resourced.  The University of Limerick’s COVID action group were preparing to convert campus facilities into a field hospital (https://www.ul.ie/covid-home/covid-action-group/covid-action-group-facilities) and university staff were preparing to return to full-time clinical duties at the expense of academic requirements.

In response to the pandemic primary and secondary schools were closed, and universities were shut down. However, medical schools and other health professional training bodies had an obligation to progress their students and send them on to clinical action. The UL Graduate Entry Medical school (https://www.ul.ie/gems/) had 125 such students who were prepared to join the workforce. 

If medical schools had closed and decided not to graduate any students in 2020 not only would there be a critical shortage of Interns this year but also a massive excess in 2021. There would likely be a domino effect as post-graduate training bodies would have a year in which they would have inadequate numbers followed by a year of having too many applicants.  Furthermore, there was no guarantee that things would get “back to normal” by 2021 with potential for further disruption and backlog.

A second approach that was considered nationally and internationally was to “just pass everyone” or to pass as many as possible based on previous or projected grades (https://www.theguardian.com/world/2020/mar/15/uk-medical-schools-urged-to-fast-track-final-year-students-to-help-fight-coronavirus).  This indeed may be a reasonable and pragmatic approach especially as the pass rates in “Final Med” tends to be 95%+ with the excess passing by supplementation. However, each individual medical school is tightly regulated by the standards of the Medical Council with regards to competencies for qualifying students and by their own universities in terms of applying grades. Furthermore, medical students are ranked based on their performance in their evaluations with regards to their applications to the Intern matching scheme.

Thus there are at least three major stakeholders in these decisions. The first are the students themselves who are not only worried about passing and failing, but also about their rank and perhaps most importantly their competency to start clinical practice. The next is the medical school or post-graduate training body which needs to be fair to students but also uphold the standards of their regulators. Finally, the medical council, acting on behalf of the general public is invested to ensure that those students who join the medical register are fit to do so.

The Show Must Go On

At this point we have decided we cannot:

·         Put everything on pause and see what happens after the closure of the pandemic

·         Just pass all students

·         Continue as previous

Thus the inevitable solution was to adapt and modify the teaching practices to train the students to the highest standard possible, assess fairly and evaluate accurately. There was a new impetus to do this as quickly as possible with a view to starting Internship as early as possible so that new doctors can join the workforce.

Switching from traditional learning environment to an exclusively online learning environment

There is ample literature on the merits of adopting blended learning strategies in medical education and indeed guidance on introducing online learning into the traditional model. However, these are all from the perspective from a very gradual and incremental change rather than a complete conversion over a weekend mid-semester. The fundamental requirements are:

·         A functional virtual learning environment (VLE)

·         a robust video conferencing suite

·         dependable IT support

·         Buy-in from senior decision makers in the institution

·         Flexibility on behalf of the course facilitators

·         Student engagement 

The UL GEMS Psychiatry Experience

For those that might not be familiar, the University of Limerick Graduate Entry Medical school offers a 4-year graduate entry programme. The school follows a Problem-Based Learning (PBL) approach in the pre-clinical years (years 1 and 2) which heavily promotes self-directed learning (SDL). This ethos is carried through into the clinical years of year 3 and 4 where students complete their clerkship style modules in General Practice, Surgery, Medicine, Paediatrics, Obs/Gynae. and Psychiatry.  Quite unlike other medical schools in Ireland, the GEMS programme delivers the Psychiatry component in the final rather than the penultimate year.

There are approximately 125 students in a UL GEMS year. They are divided into five groups as they rotate through the final clerkship modules in Year 4. They are a diverse group in terms of demographics but generally share some important qualities. The medical school experience tends to promote resilience and pragmatism which in turn is important for working as a Doctor.

Furthermore, the Psychiatry module is taught using a case-based discussion learning (CBD) approach following the principles of both PBL and SDL. Teaching for the course is delivered in two hubs (Limerick and Portlaoise) to cater for students on clinical placement across the breadth of the Mid-West and into the Midlands, from Lisdoonvarna to Naas.  To facilitate this the school has been using video-conferencing equipment for the last 10+ years. 

So not only does the programme have a flair for 3-letter acronyms but you might argue was predisposed to making a smooth transition from a face to face (F2F) or blended learning environment to wholly Online.

Overview of how we tweaked the course

Original Course	Adapted
Mixture of F2F and VC lectures synchronously delivered	Week one was F2F with all lectures online thereafter, majority synchronously some pre-recorded for asynchronous review
F2F Clinical skills sessions	Clinical skills sessions online
5 Clinical Placements	1 clinical placement
Teaching mix of CBD (70%) and lectures	Teaching mix of CBD (70%) and lectures
Assessment via paper based MCQ exam, Three 10-minute OSCES	Assessment via online MCQ and Clinical Reasoning video interpretation
In-training Assessment – case reports and reflective notes	In-training Assessment – case reports and reflective notes and recorded student videos
Number of e-modules to supplement course	Number of e-modules to supplement course
6 weeks duration	4 week duration

F2F – face to face; VC – video conferencing

Virtual Learning Environment (VLE)

There are a variety of different virtual learning environment software packages in use in Medical Education in Ireland. UL GEMS uses SULIS which is a version of the open-source software SAKAI tailored for UL needs. As it is open source it is quite modular and can be integrated with different apps and software. Other commonly used VLE are Blackboard (https://www.blackboard.com/teaching-learning/learning-management) and Moodle https://moodle.org/). Moodle is also used by The College of Psychiatry of Ireland (https://elearning.irishpsychiatry.ie/login/index.php).

The core functions of VLE are to facilitate learning, act as a repository for learning resources, allow the upload of assignments, provide administration tools and facilitate communication. With all new technology there are teething problems and bugs to iron out. The SULIS platform had been in use for over 10 years (with modification along the way) and students in UL are very fluent in its use.

Video Conferencing

While most people have experienced some form of video conferencing before the pandemic, they have probably found their use of this technology massively increased in recent times. Privacy and security are important considerations, as well as reliability. From a patient-doctor perspective there are extra demands around confidentiality, consent and GDPR and specialist suites of software have become available in the recent months.

Bigbluebutton (BBB) https://bigbluebutton.org/ was the software used in UL GEMS which integrates well with SULIS. It allows up to 100 concurrent users (this limitation has been overcome in the last few weeks), allows typical admin privileges and effectively “works out of the box”. You can partition big groups into smaller groups to facilitate small group discussion and other breakout educational activities. The software is web browser based so you don’t need to download or install other software to use it, but a camera or microphone is required.

A basic but very legitimate question is how well smart phones integrate with VLE and VC software. While the combination works in principle, the software is optimised for large rather than small screens.

A neat feature of modern VC software is some echo/reverb cancellation to reduce the disruption caused by unmuted microphones. Another tip is to use a headset or any of the fancy earphones that come inbuilt with microphones that are shipped with most smartphones over the last 10 years.

IT Support

Unfortunately, IT reliability remains one of the biggest hurdles to implementing blended learning or online learning. Both medical students and teaching staff have very little tolerance of technical issues. Behind the scenes good IT support will make sure there is adequate bandwidth and bandwidth optimisation for the VC software. UL GEMS has been very lucky in that they have IT professionals who are both knowledgeable, approachable and easy to work with.

However, one of the best interventions to make sure your online experience works is to get as familiar as possible with how the technology or equipment is supposed to work. Thankfully the vast majority of technical issues are very simple to fix, work round or avoid if you have invested just a small amount of time in getting to know the tech you are working with. You really can’t blame IT for lecturers not knowing their own passwords, etc. It is also really important to have a tried and tested “Plan B” for when things go wrong.

Buy-In from Senior Management

In this particular case UL GEMS and the wider university were completely committed to making things work and facilitating the expansion of online learning. UL GEMS already delivered a lot of material via video conference due to the geographical spread of students during term time.

Course Facilitators 

I was in the perhaps privileged position of acting as a Clinical Tutor in Psychiatry in the University of Limerick while completing a M.Sc in Medical Education. I also completed a certificate in Online Teaching from the National Forum for the Enhancement of Teaching and Learning in Higher Education. Along with my previous qualification in Computer Science and IT I found myself somewhat serendipitously prepared to pivot from a Face-to-Face (F2F) course to an Online learning environment.  My colleague Dr. Frank McKenna is similarly fluent in IT with a Business Information Systems background. In terms of his skill-set he also brought experience from sports coaching and business management so between the two of us we had a lot of the skills we could adapt to a new learning environment.

The course facilitators had a very clear ethos about their role which were:

·         motivate the students to participate and engage

·         encourage students to make substantive and relevant responses rather than token contributions

·         moderate student discussion

By striving towards these principles, we created a sense of online community in which the students didn’t feel like the online aspects were tokenistic or something that could just “dial in”. Anonymous student feedback at the end demonstrated that the students found the transition smooth, the quality of the teaching on par to their F2F teaching and generally positive in appraisal.

Student Factors

Students tend to have high intrinsic motivation and a keen interest in performing well. Their background in PBL and SDL makes them self-starters and they tend to approach things from a position of critical appraisal. However, as they are often juggling multiple requirements at the same time (e.g. applications, research and other extra-curricular activities) they are precious with their time and energy. As Graduates with ample life experience and as high fee-paying consumers, they tend to have high expectations of course quality in both content and delivery. The students also tend to have high fluency in the use of technology in education, from laptops and mobile phones, to voice recognition software to handwriting interpreting tablets.

When considering the transition from F2F to online it is prudent to consider some of the moving parts. While you might expect the entire cohort of students in a group to have access to adequately fast broadband, phones or laptops to use and a quiet and safe place to set up this isn’t always the case. UL GEMS has offered an access scholarship scheme aimed at students who entered their undergraduate degree via an Access route and who have been under-represented at University due to their socio-economic backgrounds. Nevertheless, it is important to be mindful of students who might find it difficult to engage in online learning due to shared accommodation, limited WIFI and lack of hardware so that any possible concessions can be made.

So that’s a review of how we adapted Psychiatry teaching at undergraduate level to the COVID-19 pandemic. There may well be different approaches by different schools based on different sets of requirements and circumstances and we would happy to hear about them in the comments. 

And you can follow Kevin on Twitter: @kevinly