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
