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.