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.
