Education & Training

INTRODUCTION

There is considerable evidence for the benefit of simulation among foundation year doctors.¹ Simulation training delivered during the 2 years has tended to focus on the management of the acutely unwell patient, procedures and practical aspects of delivering medical care, such as DNAR discussions, breaking bad news and capacity assessments.^2-5 However, to date, there has been less focus on the benefits of developing more complex communication skills that may assist foundation year doctors in dealing with patients with mental health diagnoses or needs. These skills may include performing risk assessments, managing the agitated patient and forming initial management plans for patients in medical settings with mental health problems. This is important, as people with mental health needs have a higher burden of physical morbidity and are hence likely to be encountered in acute care settings.⁶

Since Health Education England’s Broadening the Foundation Programme report in 2014, there has been a surge in the number of foundation trainees working in psychiatry.⁷ The development of complex communication skills was an expected natural outcome of these rotations.⁸ However, this has not always happened – foundation trainees on a psychiatry rotation have stated that they are often recognised only for their medical skills, and that assessment and management was predominantly senior-led.⁹

Taking this into account, we set out to develop a simulation-based complex communication skills programme available for all F1s and F2s based in the North Central and East London Foundation School. Our focus was on the development of the transferable skills in communication and management that would be useful for dealing with patients with mental health diagnoses in a medical setting.

METHOD

Following a pilot study in 2018, funding was secured for 2019 from Health Education England to run half-day simulation sessions to foundation trainees in complex communication skills and the management of common mental health presentations to primary and secondary care settings.

Half-day sessions took place in hospitals in North and East London hospitals. A total of 121 foundation year doctors took part in the sessions; a breakdown of this can be seen in Table 1. All sessions took place between May 2019 and March 2020.

Table 1: Participants by Site and Year

Facilitators

Each simulation group had one facilitator who offered feedback to participants. Facilitators were consultants, higher trainees and core trainees from the North and East London deaneries.

Session organisers

A session organiser was present at every session. They delivered the introductory briefing for participating doctors, provided a briefing for the actors, time-kept and held a feedback session at the end.

Venues

Four half-day sessions were run in North London, and five half-day sessions were run in East London. Three sessions were cancelled due to too few doctors registering to participate, and a further session was cancelled due to COVID-19.

Scenarios

Participants were presented with six scenarios in each session (Box 1), covering presentations in a range of settings: acute general hospitals, accident and emergency, general outpatient clinics and general practice. The sessions required skills in history taking and management when interviewing patients with complex communication needs.

Timing

Each session lasted 3 hours. Scenarios were 20 minutes each, with 10 minutes for participants to complete the set task, and 10 minutes for feedback from the facilitator, actor, and other participating doctors.

Data collection

Quantitative data

Foundation doctors were asked to complete pre- and post-session anonymous feedback forms, to ascertain their level of confidence in four domains (see Box 2): Participants were asked to rate their confidence level on a Likert scale from 1 (strongly disagree) to 5 (strongly agree) for each of these components.

Post-session feedback forms also included three questions, asking if anything could have been done differently about the day, if anything was done well, and a white space for any other comments.

Qualitative data

Qualitative data was recorded in the form of the written feedback documented post session and cross-checked by three members of the organising team.

Moderations to 2020 model

Minor changes to the format of the programme were made in August 2019, following presentation of interim findings to Health Education England. These were based on feedback generated from doctors and facilitators and are shown in Table 2. The logistics of the set-up on the day, scenarios, methods of feedback collection and analysis of data remained the same as in 2019.

Table 2: Moderations to 2020 Model

RESULTS

Quantitative data

Results showed a consistent increase in confidence across all domains following participation in the simulation session. Increases ranged from 0.83 (“I feel confident in performing initial risk assessments in a medical setting”) to 1.27 points (“I feel confident in dealing with agitated patients in a medical setting”).

Figure 1: Trainee confidence pre- and post-session by domain

There were consistent increases in overall confidence ratings at every site, ranging from 1.03 to 1.25. Similar increases in overall confidence were observed in North London (1.04) and East London (1.06).

Figure 2: Trainee confidence pre- and post-session by region

There was a 94% (n=114) completion rate of pre-session feedback forms, and a 91% completion rate (n=110) of post-session feedback forms.

Qualitative data

No changes were made to the themes following cross-checking for validity.

Thematic analysis of the free text in the post-session questionnaires generated the following themes, as below.

Quality of the stations

Trainees consistently reported positive experiences regarding the quality of the scenarios (48), actors (43), feedback (30) and facilitators (20). In particular, there was a good breadth of scenarios, they were realisticand pitched at an appropriate level. Feedback was constructive and individualised.

“enjoyed how challenging and how true to life the scenarios were”

“right level of difficulty. Took me out of my comfort zone!”

“really good to have an agitated patient as it was a very challenging scenario”

“quite clever to have capacity assessment in somebody with capacity because it’s harder in some ways!”

Five trainees would have liked to have had more scenarios, and three suggested that it would have been useful for the facilitator to have demonstrated a ‘model’ example of a scenario at the end of the session.

Environment/logistics of the circuit

General comments included that the circuits were well organised, and that there was a comfortable atmosphere for giving and receiving feedback. Eight trainees commented that the group size was too big (all were attendees at the Homerton session in 2020, which was the largest session run with 33 trainees in attendance).

Preparation of candidates for the circuit

Ten trainees (seven in 2019; three in 2020) said they would have liked clearer briefings or objectives for the scenarios – two trainees specified that this was in relation to the capacity assessment station.

DISCUSSION

Our results suggest that simulation training involving actors with mental health diagnoses can help foundation year doctors build confidence in their approach to such patients in a medical setting.

The greatest increase occurred in participants’ confidence in dealing with an agitated patient. It is likely that participants felt the most anxious about this prior to and during the session. Thus, they were able to gain a more immediate sense of progress in this domain by being able to practice this in a ‘safe space’ and after being able to see a visible de-escalation of the patient during the station. Participants also valued receiving supportive feedback from the actor, facilitator and their peers.

Participants also demonstrated large increases in confidence with respect to formulating initial management plans. This was the domain trainees were second least confident in prior to the session. It is likely that some trainees would be anxious about whether they have enough clinical knowledge when formulating an initial management plan for mental health patients. The chance to practice this in a controlled setting, with pertinent feedback, appears to have bolstered confidence.

Results were consistent between sites, suggesting that the content of the course, the experience of being in the roleplay itself, and the chance to receive feedback from experienced clinicians were of the most importance to participants, and local variations in delivery did not impact on participants’ experience to a great extent. The wide participation among foundation trainees in North and East London (121 trainees across two regions of London, over nine simulation sessions) suggests that there is a demand for such sessions and there might be an unmet need across other deaneries.

Qualitative data analysis showed positive feedback relating to the quality of the actors, the facilitators and the scenarios themselves. This likely contributed to the trainees reporting that the simulation was realistic and pitched at the right level, hence they were able to find benefit from them.

Limitations

There was a large difference in the number of participants enrolled in each session (three in the smallest, 33 in the largest). This will have given rise to a difference in experience between these participants, with the smallest group being able to partake in all six scenarios, and the largest group only being able to partake in one. This may have meant that those undertaking all six scenarios may have been exhausted by their experience, whereas those undertaking one may have felt that they did not get enough opportunity to practise. Confidence scores between these two groups were relatively similar, but it is unclear whether there would have been a difference if they were of similar size.

Linking of pre- and post-session feedback questionnaires to the respective trainees would have also enabled testing for statistical significance. A paired t-test could have been used to assess the increase in confidence observed by our simulation sessions in each domain.

This study tracked changes in confidence among foundation year doctors following a simulation session, but it did not assess the impact on their actual practice. This would be important to ascertain, to see if the session has allowed foundation year doctors to build on their experience of assessing and managing mental health patients in a medical setting. As a result, a cohort of participants has been selected for future contact regarding this to determine the potential impact on their clinical work.

Introduction

Health Education England (HEE) runs the Medical Training Initiative (MTI) scheme on behalf of the Department of Health (the Government Sponsor) and is influenced by the Home Office Tier 5 Government Authorised Exchange Visa Scheme¹. The Academy of Medical Royal Colleges is the national sponsor for visa purposes. Major stakeholders involved in this scheme are the GMC and GMC Approved Sponsors (e.g. Medical Royal Colleges), Postgraduate Deaneries/Local Educational Training Boards (LETBs), and National Health Services (NHS) Trusts, with support from the Department of Health.

The Royal College of Psychiatrists (RCPsych) Medical Training Initiative (MTI) Scheme enables qualified overseas psychiatrists to undertake training posts in the National Health Service (NHS) for a maximum of two years (2). The purpose of the scheme is to provide training opportunities for international psychiatrists in the UK to improve capacity as a professional and return home with broad knowledge and experience. Vacant core training (CT3) posts approved by Deaneries/LETBs are offered to eligible international doctors. Thus, the MTI psychiatry scheme can benefit overseas doctors, the NHS and the countries that trained them.

Although the MTI scheme was first established in 2009, the RCPsych only formally adopted the program in 2014. Some lessons were learned from the experience of the scheme in other specialities and provided an opportunity for the RCPsych to develop its own scheme. It developed a selection process for successful candidates and matches them with relevant placements in NHS trusts across the UK. This process takes into consideration the training needs of the overseas doctor and vacancies available in NHS trusts. The MTI Psychiatry Scheme is now in its sixth year and has gradually grown over the years as evidenced by an increase in annual allocation of the training post to 40 placements, a rise in the number of applicants from different regions of the world and an increase interest from employing NHS trusts. However, there are areas for further development in this scheme and there is a need to ensure that it consistently provides a good training experience to international doctors.

Various researches suggest that there are diverse difficulties faced by overseas doctors during their transition into a new country ^3,4. Lack of information about NHS; clinical, educational and work-culture challenges; language and communication challenges; and discrimination challenges were issues experienced by international doctors while initially working in the UK hospital settings ⁵. The College has recognised these difficulties and wanted to understand how these are impacting on the international doctors and what can be done to help them.

Aims

The aim of this survey was to evaluate the trainee’s experience of the MTI psychiatry training scheme and explore difficulties during the training and what can be done to help. The purpose of this survey was to gather feedback on the current implementation of the MTI scheme.

Methods

An anonymous online survey consisting of 28 questions was sent to doctors using SurveyMonkey as part of the RCPsych Annual MTI survey. All doctors enrolled in MTI Scheme were identified through the RCPsych MTI mailing list. The survey was open in November 2018 for one month.

Results

Out of seventy-six, a total of thirty-one trainees completed the survey with a response rate of 40.78%. Most of them (n= 13) were from the age group 31-35 years. The findings of the survey are summarised in Table 1-3.

Table 1: Description of MTI doctors (n=31)

Table 2: Induction, Supervision and Mentoring (n=31)

Table 3: Work experience in MTI scheme (n=31)

Reasons for choosing MTI Scheme

Training opportunities in the UK were considered by three quarters of the respondents for joining the MTI scheme. However, about half of the respondents reported job prospects, recommendation from senior colleagues and college reputation as pull factors.

Clinical and Educational Supervision

Three-fifths of trainees had weekly supervision with their designated clinical supervisor and three quarters (75%) of them rated the quality of supervision as either good or excellent. The majority (93.54%) of them had an educational supervisor and less than half met the supervisor 1-2 times per year. RCPsych has a mentoring scheme to support MTI doctors but half of the trainees (51%) did not have a mentor.

Out of hour support

Less than one-third of the trainees were never forced to cope with clinical problems beyond their competence. However, three-fifths of trainees reported that they always had access to out of hour support and advice.

Challenges encountered

Lack of knowledge of regulatory framework was reported by three-fifths of trainees while working in the UK settings. In addition to that, half of the trainees reported a lack of knowledge of NHS and cultural differences. One third had difficulty regarding multidisciplinary team settings and varied levels of support and training. About 51.61% felt that their clinical training was secondary to service and few reported feeling unsafe, being bullied and being punished.

Discussion

This is the first evaluation of the training experience of MTI psychiatric doctors. This study showed that most of the trainees had good work experience of psychiatry before coming to the UK. One of the undoubted strengths of the MTI psychiatry scheme is the recruitment of international psychiatrists with skills and experience of working in diverse cultural backgrounds and low resource settings. This is one of the potential benefits that the NHS can draw whilst delivering the health care smoothly. The majority of respondents in the present survey cited training opportunities as the main reason for choosing the MTI scheme. Child and Adolescent Psychiatry, Old Age Psychiatry, Addiction Psychiatry and Forensic Psychiatry were the subspecialties that received the highest interest in the MTI post in a 2017 survey ⁶. It is encouraging that most doctors were keen to gain further experience and training in subspecialties that were not readily available in their respective home countries.. A similar finding has been reported in the Royal College of Anaesthetists’ annual MTI survey where the majority chose subspecialties that were poorly developed in their respective countries, e.g. ICU and pain⁷.

Transition to the UK is not a smooth process for overseas doctors and must be supported during this transition phase (5). Lack of knowledge of the NHS, regulatory framework and cultural differences were the challenges faced by most MTI doctors in this study. The RCPsych International Medical Graduates (IMG) conference acknowledged that IMGs face more problems than British counterparts in succeeding in the system and recognised the importance of trainers, the role of employers in developing meaningful induction programmes and giving IMGs additional support and remediation if required⁸. This study showed that most of the trainees had attended local induction in the workplace before starting a job. Induction course content must be relevant and reflect issues concerning overseas doctors ⁹. It is particularly important to remember the specific needs of overseas doctors as they were trained in culturally diverse and low resource clinical settings. Several studies have shown that a structured induction program is a useful way to integrate doctors during the transition to the NHS^10-12. Few trainees missed the local hospital induction as they arrived in the UK months later than expected and the trust could not arrange the training. With this hindsight, RCPsych organises the annual national MTI induction program to the new doctor in this scheme to complement and compensate for any shortcomings in the local hospital induction.

MTI posts should provide the trainee with an opportunity to train in a highly supported environment. Supervisors provide regular support and ongoing feedback during the training. Trainees value the support they receive through supervision, senior and peer support, and the opportunity to work in multidisciplinary team ¹³. It was reassuring to find that three-fifths of trainees had weekly clinical supervision as recommended by the Royal College of Psychiatrists.The quality of clinical supervision was rated as good by 51.61% of trainees and 22.58 % reported as excellent. Most of them had access to out-of-hour support/advice. Supervision is important for continued professional development as international doctors need more support than UK trained doctors ⁹. Unfortunately, few reported serious issues such as being bullied at the workplace and feeling unsafe. A survey of bullying of psychiatric trainees in the workplace reported that it was experienced equally by both IMGs and UK graduates, but IMGs were less likely to report the incident to the organisation¹⁴. It is important to educate IMGs about the mechanisms to escalate this concern for proper action. Besides that, it would also be prudent to include these pertinent issues during the annual MTI induction program to raise awareness among IMGs.

The MTI doctors had identified areas for additional support from the College, trusts, local deaneries, and senior colleagues in the 2017 annual survey⁶. The College took the following steps:

1. Annual MTI Induction Program: Full day induction program is held annually in the Royal College of Psychiatrists’ for new doctors in the scheme. The program is specifically tailored for doctors who are working in the UK for the first time. Highlights of the program include an introduction to the NHS, Good Medical Practice, Psychiatric training in the UK, ‘Person-Centred Care’, resources and support available for trainees and most importantly, communication skills workshop. It also provides an opportunity to meet with other MTI fellows and share experiences and set up informal support networks such as WhatsApp group. Twenty-three doctors attended the MTI induction program in 2019. Not all doctors recruited in the MTI scheme were able to attend the annual induction program because of the variable start date resulting from delay in visa processing. RCPsych could provide support to these IMGs by organizing the induction program two times a year.

2. MTI Mentoring Scheme: RCPsych runs a mentoring scheme and has been offering mentorship to MTI doctors for the past three years (15). Mentors are usually experienced RCPsych members who have volunteered in the mentoring scheme. RCPsych MTI team matches the mentor and mentee who will stay together for the duration of the placement. The current study shows that 50% do not have a mentor. We did not explore the reason for this, but we speculate that as doctors must actively express their interest in participating in this mentoring scheme and this might have shown less engagement.

3. Annual MTI Scheme Survey: Feedback is collected from MTI doctors each year as part of ongoing efforts to improve the RCPsych MTI scheme.

4. Sharing of experiences about the scheme between the trusts: Trust has varying levels of experience regarding the training scheme and the College has been facilitating the exchange of shared experience by the experienced trust to a new host trust.

This survey explored the experiences of doctors involved in the MTI scheme and it would be interesting to know findings from longer-term studies. Longer-term follow-up studies are needed to evaluate the positive impact of the scheme after the doctors return home on completion of the training. It is hoped that invaluable insight gained from the survey can be used to strengthen the scheme as well as provide learning points to other specialities with similar training scheme for international doctors.

Conclusions

This survey provides useful information regarding training experiences in the MTI psychiatry scheme. The first step in making the difference is getting feedback directly from those involved in the scheme. RCPsych MTI Scheme is an evolving program and measures were put in place to address the needs/concerns that emerged from the survey to enhance the training experience of the MTI doctors.

Background and rationale

Psychiatric trainees in Iraq face many challenges that limit their immediate access to improved training opportunities. These include limited access to classroom teaching, regular clinical supervision meetings and fewer opportunities to attend international conferences and placements. These challenges are more acute in those specialities with the greatest shortage of consultants (for example, forensic and child and adolescent psychiatry).

Furthermore, the fragile security situation in the capital and larger cities and the post-conflict disruption to educational institutions consequent to these difficulties makes it difficult for those in the UK and elsewhere to visit the country and support educators and training on the ground.

Against this background and as a medical educational team in the UK (Oxford University Medical Education Fellows, OUMEF) with an interest in developing training opportunities for peers and colleagues in Iraq, we set up the Oxford Psychiatry in Iraq (OxPIQ) Project, beginning with a project development team that included Medicine Africa, an experienced online distance learning platform.

So what is the role of TEL in the delivery of online distance learning targeted at medical professionals in these circumstances?

Meeting the Challenge – the role of TEL

The concept of Technology-enhanced Learning (TEL), or Web-based learning (WBL), defined as the use of information and communication technologies in teaching and learning ¹, is a relatively new phenomenon. Nevertheless, there is a considerable body of evidence supporting the use of TEL in various clinical and non-clinical settings.

Mccutcheon et al. ² systematically reviewed thirteen studies and found that ten of these studies concluded that online learning is as effective as traditional or classroom teaching, despite the limitations of some of these studies.

In a large meta-analysis, Means and colleagues ³ concluded that students using online teaching performed modestly better compared to students learning similar material using face-to-face teaching. Combining face-to-face and online teaching resulted in larger benefit compared to the use of face to face methods only.

TEL can address the learning limitations in classroom settings due to expanding curriculum coverage and limits on contact time between students and lecturers/trainers alike. It can contribute to better use of such face-to-face classroom contact through the facilitation of the flipped classroom approach. ⁴ In this approach (also called inverted instruction and upside-down teaching), students acquire the basic information of the lesson outside the class (usually using online materials) and then develop their knowledge further in the class by sharing their learning, interacting with other classmates and teacher, and discussing various aspects of the study topic.These advantages have enabled TEL to revolutionise distance learning at many levels – enabling greater access to education by overcoming geographical and time-zone boundaries.

An allied concept within distance TEL is the concept of virtual teams ⁵ where health professionals come together to teach and learn from each other independent of location. Of itself, this offers some advantages. These include the possibility of addressing speciality-specific training gaps through the incorporation of the relevant expertise within the team - and to the creation of what is termed “connectivism”. This term refers to the use of internet technologies to enhance learning through online peer networks ⁶ and the development of communities of practice. ⁷ The latter allows for workplace-based learning with trainees learning from more experienced practitioners and moving towards the same through greater competency acquisition.

In a similar vein, creating networks of professionals may help to establish more longer-lasting relationships of mutual benefit between the UK and Iraqi professionals (e.g. through collaboration on training programmes, conferences, etc.). Also, cross-cultural online learning has been shown to be very useful in improving language skills and cultural awareness of learners and educators. ⁸ With language translation technology, any language difficulties can also be overcome, especially if the educator can observe the learners’ responses to the translated text and offered the opportunity to give further explanations and clarifications when necessary. ⁹ Finally, as well as sharing knowledge and experience within groups, TEL enables opportunities for mentoring and coaching individuals. ¹⁰

For our purposes, these findings and opinions support the use of online learning as a suitable distance learning “add-on” to existing training opportunities in Iraq.

TEL and Learning Theories

Learning theorists suggest that experiential and constructive learning theories are most appropriate to learning in the clinical context. Both are possible with TEL (as well as being facilitative of behaviourist and cognitivist approaches).

For example, the virtual classroom environment can enhance the learning experience of the participants by improving their analytical skills by thinking through case formulation and management plans. ¹¹ Participants in online learning could be assessed and receive the feedback immediately. Ideas can be shared, and there is no passive acquisition or transfer of knowledge as is the case with traditional lectures. These aspects have implications for the design of the educational sessions and are discussed below in the learning methods section.

Challenges of Online Distance Learning

There are many challenges associated with online distance learning. Firstly, there is the potential lack of the required technologies (internet access, laptops or desktop computers), the expenses of subscribing to these online learning templates, the need to have technical support, and similar technical and logistic issues. ¹² These technical problems may impair access to and functioning of the virtual team. The choice of an experienced online platform must, therefore, be considered carefully.

Secondly, there may be ethical issues about the protection of patients’ confidentiality in these sessions, especially when there are different laws of privacy that are applied in the UK and Iraq. This will require knowledge of the relevant professional requirements by the tutor team for example.

Furthermore, the student-teacher relationship has traditionally been underpinned by direct face-to-face contact and being present at the same time and place. ¹¹ Therefore, learners and educators might be less satisfied with online learning. For these reasons, the concept of blended learning (careful integration of online learning with face to face learning experience) has been developed to overcome the limitations of a standalone online or face to face learning and has been found effective and applicable in various settings. ¹³

Thirdly, any distance online learning programme must understand and support existing “local” training provision and arrangements, in the classroom and the workplace. This requires liaison and cooperation with the training providers and institutions on the ground.

For clinical training to be relevant, it needs to reflect the learning needs of trainees in the workplace – in keeping with adult learning principles and cognitive apprenticeship models of learning. ¹⁴ The latter includes the importance of clinical decision-making underscored by the higher levels of Bloom’s (1956) cognitive domain. ¹⁵ To this end, then appropriate learning and assessment methods are needed to enable effecting learning.

In other words, while necessary, TEL may be insufficient in enhancing learning outcomes if allied learning methods are not chosen appropriately. Also, in our view, TEL is not a substitute for bedside teaching.

Table 1 summarises this appraisal of online distance learning (using the online platform provided by MedicineAfrica).

Table 1 Strengths and limitation of using MedicineAfrica (web-based virtual classroom environment)

OxPIQ & Project Development Team

OxPIQ is a partnership between Medicine Africa and psychiatrist members of the Oxford University Medical Education Fellows, with experience of working in Iraq. The Oxford University Medical Education Fellows (http://OUMEF.org) is a group of trainees from across medical and surgical specialities with interest in medical education and training.

Medicine Africa (http://medicineafrica.com) is an innovative clinically targeted online platform developed in collaboration with King’s College London’s Centre for Global Health, within the King’s Somaliland Partnership. Built at low bandwidth, it enables collaboration between medical professionals in the UK and those in remote or fragile states to enhance education in various clinical specialities using online sessions (live courses and mentoring sessions). Please see Appendix 3 for a screenshot of one of the active sessions of OxPIQ.

Following the development of a project team, additional team members were added from the Subcommittee on Iraq of the Royal College of Psychiatrists (http://www.rcpsych.ac.uk/workinpsychiatry/internationalaffairsunit/iraqs...), thus completing the UK dimension.

The next step was to invite representation and support from the Iraqi Board of Psychiatry and the Medical Education Unit in Baghdad. These developments led to the formal launch of OxPIQ Partnership in March 2016. Later on, the many UK and Iraqi doctors joined the Partnership as tutors and learners.

The Virtual Learning Team: Trainees, Specialty Consultants & Tutors

Iraqi psychiatry trainees were then recruited, and their more pressing learning needs to be appraised based on their views and those of the Iraqi Board of Psychiatry supervisors. Learning needs to emerge included the management of older patients with dementia and functional disorders, assessment and management of children and adolescents (with autism and ADHD for example), forensic patients and those with drug and alcohol addiction. The team thus formed was composed of up to ten psychiatry trainees from Iraq and five senior psychiatrists/tutors each, from Iraq and the UK respectively. A schedule of fortnightly seminars was agreed and published on the learning platform. Case-based discussions were used as the main educational activity during these seminars.

Learning Methods and Processes

As noted earlier, the importance of experiential and constructivist learning methods are key to clinical education. Our literature appraisal revealed that they are essential elements of successful TEL in this context too. ^{16, 17} To these must be added learner engagement. ¹⁸

Virtual or online (anonymised) case-based discussions (CBDs) are valid and reliable learning tools. ¹⁶ They are interactive and centred around the students and their learning needs while a facilitator guides the process of learning. Learners are engaged through discussion of actual clinical cases, so preparing learners for real-life experience. ¹⁹ Also, expert facilitation and peer feedback to trainees promotes clinical knowledge and skills’ development. ^{20, 21}

Effective small group teaching is characterised by four main strengths: flexibility, interaction, reflexivity and engagement. ²² Flexibility is when the teacher responds to the needs and learning of the students dynamically and helps them to explore wider pedagogic spaces. A higher degree of interactivity is usually seen in small group teaching compared to a larger group. Teachers are better able to continually engage in self-reflection and listen sensitively to students in a small group and observe the dynamics between the members of the group, leading therefore to better reflexivity. Engagement refers to encouraging the students to develop their academic identity and engage in lively debate about the various aspects of the topic discussed.

We aimed to replicate these characteristics. For example, a small group discussion allowed better interaction with each participant (interactivity); the presence of chat windows enables the facilitator to self-reflect on the process, monitor engagement and respond reflexively using questions and answers to stimulate interest and respond flexibly to individual trainee knowledge gaps. Tutors are encouraged to identify trainees’ learning needs and facilitate interactivity, and timely feedback as these are highly valued by the participants and help to keep them motivated and engaged. ¹⁸

For further reading in this area, we recommend Brindly and colleagues’ ²³ ten strategies to increase students’ motivation towards and engagement with online learning (see table 2).

The focus of the Lesson Plan Design

To these ends, the focus on the lesson design was on using problem-based learning methods (e.g. CBDs) within a small group setting (between 4-12 members) and a format that promoted learner engagement. A sample lesson plan is provided in Appendix 1.

In practical terms, tutorials were held fortnightly in term-time. All participants received an email notification to inform them of the session topic, and the tutor uploaded the slides from the session to the website beforehand. Participants logged-in to the site (http://medicineafrica.com) and interact with the tutor by voice (requiring only simple microphone equipment) and by writing in a chat window.

Evaluation and feedback gathering

The evaluation of the effectiveness of these sessions was reliant originally on trainees’ immediate reaction (table 3, level 1 evaluation, Kirkpatrick ²⁴) using formal feedback tools provided online by MedicineAfrica. This feedback was shared with tutors and the Project Team. Please see Appendix 2 for the template used in collecting feedback after each session.

Subsequently, members of the project team approached trainee representatives, tutors and Iraqi Psychiatry Board leads separately for further feedback and appraisal of learning needs. Furthermore, some months after a tutorial we have asked trainees for evidence of learning across the higher levels of Kirkpatrick’s evaluation model.

Regular feedback from the Iraqi and UK participants has been positive. The sessions have been associated with improved clinical knowledge and skills of the Iraqi Psychiatry Trainees. Requests for certificates of tutorial participation have been agreed upon and provided by the project team addition, so supporting learners’ (and tutors) portfolio development.

Table 3 Kirkpatrick’s (1996) Levels of Training Assessment

Further cooperation

A surprising (and very welcome) outcome of the project was, through the facilitation and support of the Iraqi Board of Psychiatry, the introduction of educational workshops in Baghdad. These workshops were held in Medical City, Baghdad, in May 2017 and April 2018 and were facilitated by tutors (YH & H Al-T) from the OxPIQ Partnership. They covered targeted topics such as old age psychiatry, addiction, organic and forensic psychiatry. Trainees and senior psychiatrists from Iraq attended; their feedback showed how they valued the interactive nature of the teaching and use of CBDs as learning methods, resulting in high levels of engagement.

Conclusions

This paper describes the process of designing, delivering, and the early evaluation of an online distance TEL programme for mental health professionals based in the UK and Iraq.

TEL has had an important role in overcoming the geographical barriers and other challenges to developing training opportunities in Iraq and other developing countries. We are of the view that it could be used more often to connect professionals working in similar circumstances and with other disadvantaged groups, including refugee and asylum seekers. It is a flexible way of providing training to professionals working with those groups in relatively remote and resource-deprived environments.

Greenhalgh ²⁵ suggests that three factors are needed for the success of online educational activity: ease of access, perceived usefulness of the activity to the learning requirements of the students, and the interactivity of the session. In our experience, these are important. Also, we believe that additional consideration should be given to (i) working with an experienced online platform provider; (ii) working with local educational institutions, trainers and learners to identify unmet learning needs and support existing learning opportunities/programmes; and (iii) adopting an iterative approach to feedback and evaluation.

Appendix 1: Example of a Lesson Plan

Appendix 2: Feedback form to be completed by the participants after the session

Appendix 3: MedicineAfrica screenshot during an active session

Introduction

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.

Background

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.

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.

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.

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.

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:

Limitations

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⁾

Introduction

Postgraduate medical training should equip trainees with the skills, knowledge and attributes for independent practice¹. They need to be equipped with the skills to become lifelong learners and continually develop their abilities throughout their careers by learning from colleagues, mentors, patients and disease. The challenge for clinical teaching is how to provide an optimal learning environment in which trainees can achieve their competencies for practice within a defined training rotation; both the limitations in the number of hours within a working week and the balance between learning and service commitments all can negatively impact on the educational experience of trainees². Moreover, trainees need to balance their own development of skills, knowledge and attributes for independent practice against the requirement to provide high quality and safe healthcare³. The appropriate level of supervision must be provided to trainees performing any patient interaction and this is gauged by the trainer-trainee relationship, regular assessment and feedback. The clinical workload of a trainee needs to be finely balanced between overstretching them with tasks outside their competencies and being left with all the routine and menial tasks⁴. Thus whilst trainees should work within their competencies, they must be given the opportunities to expand their repertoire of skills, which may result in errors (and potentially patient harm) – supervision should limit these errors, which should be reflected on to provide a learning opportunity within a ‘no-blame’ culture⁵. As a trainee gains competence of their necessary skills, the amount of supervision required can be stepped down, until distant supervision (i.e. advice via a telephone) may be all that is required.

An understanding of how each learning environment within the hospital setting can be maximized may enhance the learning opportunities conferred upon trainees. Both technical skills and the professional attributes of being a clinician can be learnt in clinical and non-clinical environments. These learning environments will be explored in the subsections below.

Bedside Teaching and Ward Rounds

Bedside teaching is a stalwart of medical education, allowing clinical history and examination to be performed under guidance, in an appropriate setting and with relevant clues (observation charts, oxygen, etc.) present. This patient-trainee interaction provides an opportunity to develop professionalism and communication, and can also be the source of training of diagnostic techniques ranging from venesection and cannulation to more invasive techniques (e.g., pleural aspiration, drainage of ascitic fluid)¹.

Presentation of patients during ward rounds allows a professional conversation between trainees and trainers to occur, which justifies their role in management and provides an insight into understanding and thought processes⁶. The multidisciplinary nature of rounds creates a community of practice⁷, allowing social learning to occur, and an opportunity to voice differing perspectives on patient care³. In order to maximize these learning opportunities, learning objectives can be discussed prior to commencement and reflection undertaken once they it has been completed⁶. Teaching rounds should be carried out when the ward is quiet, at a suitable pace, with regular questioning and opportunities for trainees to ‘lead’ the process⁸. Factors that hinder this educational process include time pressures, patients not being available, and the availability of trainees⁸.

Outpatient Clinics

Outpatients provides a mixture of new and follow-up patients that enables a trainee to learn management of patients in an ambulatory setting. Trainees may be in the same room as their supervisor (learning the basics of the consultation), or can practice semi-autonomously as their experience increases (with discussion with their supervisor as required); they must select an appropriate investigation and treatment plan, with a time frame for review, once the investigation or intervention has been performed³. Outpatient teaching is more highly valued by trainees and students compared to ward based tuition⁹. Factors that hinder this educational opportunity include room availability, time constraints, staffing levels and attitudes to teaching⁹.

Operating Theatre and Interventional Suites

Invasive procedures should be performed by adequately trained (or supervised) personal in the relevant area of the hospital (e.g. endoscopy, interventional radiology suites, theatre), with the necessary equipment and monitoring for the technique to be performed. Even before patients enter these environments, trainees have an opportunity to review the patient and their relevant investigations, discuss the procedure with the patient and obtain consent for the intervention¹. Trainees can learn a wide spectrum of skills within these environments including both technical (both procedural related and anesthetic related) and non-technical skills, including Human Factors, anatomy, identification of instruments, aseptic technique, effective hand-washing and donning of surgical gowns¹⁰. Teaching invasive procedures represents a dichotomy for clinicians, not only do trainees need to gain exposure and experience in the relevant technique, but patients need to be prevented from undue harm. Prior to undertaking an intervention, trainees should be familiar with the relevant anatomy and physiology of the system they are about to operate upon, will have watched the procedure being performed and may have learnt the basics of the procedure in a simulated setting.

Trainees must to be able to self-reflect on their own skills and record of the number of procedures they have performed (which can act as a proxy for ability) to ensure that the correct level of supervision is provided alongside an intervention of suitable difficulty. Trainers need to be sure that their trainees have the necessary skills and knowledge to perform a technique, with experience often being gained in a stepwise reflecting both the difficulty of intervention and the gaining of skills, competence and confidence by the trainee¹¹. This skills acquisition should be accompanied by regular discussion and feedback to maximise learning opportunities; when no supervision is available, trainees should consider video-recording the procedure as this allows reflection and review at a later date. A video diary can also be used as a portfolio of a trainee’s repertoire from beginner to expert during their training rotation. The challenge for trainees is to achieve competence in the relevant invasive technique within their training rotation; the number of interventions required to gain competence will vary between each trainee and technique¹¹.

Handover

Handover allows the care of patients to be transferred from one group of individuals to another on a temporary or permanent basis. Handover confers an opportunity to present a clinical synopsis of patients with key information to ensure continuity of care and patient safety is maintained³. Most handovers are trainee led which provides an opportunity for peer learning to occur, checking comprehension and sharing interesting cases or tips for practice¹². Handovers should be considered to be a high risk procedure, as communication errors can result in vital information being omitted; as such the process should be undertaken in suitable environment away from distractions, in a structured written and oral manner supported by an electronic format¹². A further review at the patient’s bedside can be performed if required, which can highlight high risk patients.

Multidisciplinary Team Meetings

Multidisciplinary team (MDT) meetings are small formal meetings focused on all aspects of a patient’s care that involve a wide range of medical personal, nursing staff and allied health care professionals¹. Meetings ensure that evidence-based guidelines are followed, and help to streamline management, removing unnecessary delays in treatment and improving cost effectiveness. MDTs represent a Community of Practice⁷ allowing social learning to occur as each individual can share their relevant expertise; MDTs enable best practice to be shared and help break down barriers between different specialties.  Trainees can learn from the didactic teaching that occurs within the MDT (in relation to clinical details, investigation and management), but can also contribute to the meetings and practice their presentation skills.

Morbidity and Mortality Meetings

Morbidity and Mortality (M&M) meetings can help ascribe accountability and be used to highlight improvements in patient safety. They provide an opportunity for professional education, especially if the discussion can be held within a no-blame culture, and the meeting can voice discrepancies in how to manage patients, especially in ambiguous situations¹³. Trainees may be tasked with presenting a case and the potential learning aspects associated with patient care.

Grand Rounds/Formal Teaching

Grand rounds are traditional formal teaching opportunities that typically revolve around a case, whereby salient findings are presented prior to a discussion of management. These meetings allow opportunities for trainees to present cases and learn management, but their educational benefit may be decreasing as they are being replaced with lectures with limited clinical relevance¹⁴. However “audience apathy, deteriorating decorum and shrinking attendance” have diminished these learning opportunities¹⁴. Targeted teaching and the establishment of learning objectives for trainees can improve the educational content and the provision of feedback to the speakers can also enhance these meetings.

Journal Club

Journal clubs confer an opportunity for current scientific research and developments to be presented, critiqued and discussed by trainees. These clubs confer an opportunity to appraise the current literature and how that can be translated into evidence based patient care¹⁵. Journal clubs tend to be both voluntary and occur outside of working hours, resulting in highly motivated groups of participants whom are protected from interruptions.

eLearning and mLearning

Electronic learning (eLearning) and multimedia learning (mLearning) enable trainees to work informally, away from desks and computers, and at their own pace through a series of educational modules. Any intervention that engages trainees and promotes learning should be encouraged and these online learning platforms can be combined traditional learning resources should be promoted to ensure that all aspects of the curriculum are covered. mLearning in particular  can be ‘dipped into’ allowing the learner optimal flexibility of how and when they want to use it. elearning can be referred to during point-of-care patient interactions when a trainee is unsure of how to proceed with patient management¹. These increasingly important and under-utilized resources should be supported by educational institutions that support both undergraduate and post graduate trainees. By developing a virtual learning environment, individual tailored learning programs can be created that allow a trainee to develop and control their own online learning¹⁶.

Simulation

Simulation is becoming increasingly important for medical training. , anything can be simulated from learning clinical skills to human factors training, for both individuals and teams, focused on patient care and current medical practice in both the undergraduate and postgraduate setting. The availability of simulators coupled with competency based training and a decreased amount of training within the workplace has led to an increase use of this teaching format¹. In addition, trainees need to understand how to use certain pieces of equipment prior to employing them on patients and this familiarity can only be gained in a simulated setting. Simulation can either occur within the workplace (allowing point-of-care simulation to see how teams react in a situation) or on formal taught courses; it can be low-technology and cheap (e.g., tying surgical knots on the back of a chair), but can also be high-fidelity and expensive (e.g., a virtual reality training simulator for laparoscopic operations), or use animal or cadaveric tissue. Simulation that increases trainee’s familiarity with certain techniques is likely to improve their clinical performance, decreasing potential patient harm and shorten the time taken for trainees to achieve competence¹. A simulation should be completed with feedback from the supervisor to ensure that trainees gain the most from the session and clarify any facts or concerns about the simulation; a video recording of the session can also enable participants to reflect on their performance in a manner that is almost impossible in everyday clinical practice.

Introduction

The CASC (Clinical Assessment of Skills and Competencies) has been running since 2008 and is the final membership examination for the Royal College of Psychiatrists (MRCPsych).¹ It is a clinical examination and follows an OSCE format (Objective Structured Clinical Examination), where candidates move through 16 short stations.^2,3 We have been running a mock CASC in the West of Scotland for the last few years and have received consistently good feedback from candidates. This article describes our experience of organising the mock exam.

Step 1: Practicalities

The organising committee

Our mock CASC is arranged by the organising committee for the local core psychiatry education programme (MRCPsych course). This committee is comprised of a consultant chair, higher trainee chair and one or two trainee representatives from each higher subspecialty and each core training level. The higher trainee chair takes the lead with organising the mock, with the support of other committee members. This works well, as the trainees have recent experience of sitting or preparing for the exam and are enthusiastic about medical education.

Support from our postgraduate operations manager is invaluable. She works closely with the committee to book the venue and actors, and order equipment such as screens and a bell. She also has a key role in advertising the mock exam to trainees, booking places and being a point of contact for candidates. She assists with set up on the day of the exam and prints station instructions, marking schemes and labels for candidates.

Venue

Our mock exam is held in the same venue as our core trainee educational programme. We have 2 rooms to use for stations and a waiting area for candidates. Screens are borrowed from Glasgow University Medical School to create separate stations.

Timing

The mock exam takes place around 2 weeks before the CASC. This enables candidates to have prepared for the exam and leaves some time to work on any issues identified by the mock. Planning usually starts 4-5 months in advance of this, with increasing intensity and time commitment as the exam approaches.

Step 2: Mock Exam Format

CASC format and blueprint

The CASC itself includes morning and afternoon circuits, which all candidates will move through. There are 16 stations in total, with 90 seconds between each to read the task instructions. The morning session comprises 4 pairs of ‘linked’ stations, lasting 10 minutes each. In these paired stations, the second station is connected to the first in some way, such as taking a history in the first part then discussing with a family member in the second. Each station is marked independently. The afternoon consists of 8 single stations, lasting 7 minutes each. A passing list is posted online after a few weeks, with specific feedback made available to unsuccessful candidates.²

Mock CASC format

Our mock CASC is run in one afternoon session from 1.30-5pm. We have been able to include 16 stations by running the 2 circuits simultaneously. To make this possible, each station is 7 minutes in duration, with 90 seconds between stations. 4 candidates start after a delay, as it is not possible to start on part 2 of a linked station. Trainees are allocated candidate numbers and starting stations for both circuits to coordinate this effectively (figure 1). 16 candidates can take part in the mock exam.

Figure 1. Candidate numbers

At least 3 other higher trainee helpers are recruited to assist the coordinator on the day of the exam. The same marking scheme is used for each station, covering domains common to all stations, such as building rapport and range and depth of questioning. There is also space for specific feedback, which examiners are encouraged to provide, though they do not interact with candidates directly during the exam. Forms are completed contemporaneously and distributed to candidates immediately after the mock exam.

Step 3: Writing the Stations

The content of the CASC follows a blueprint, which is available through the RCPsych website. A variety of skills are tested during the 16 stations of the exam, including history-taking, mental state examination, risk assessment, cognitive examination, physical examination, case discussion and difficult communication.³ We refer to the blueprint when selecting which stations to include in the mock. Each year, recent CASC candidates are asked to suggest stations and we combine these with previous stations to construct the mock exam. New stations are written by the trainee who suggested them, including candidate instructions and actor’s notes. The higher trainee organiser formats these to maintain consistency across the mock exam.

Role-play actors

For our most recent mock CASC, we employed paid actors for every station. These actors are part of a local agency which has experience in working as simulated patients for Glasgow University exams and communication skills sessions. In previous years, we have recruited a combination of core/higher trainees and actors. We have found pros and cons to each approach. The use of paid actors was more realistic for trainees but writing scripts proved more challenging as instructions required greater detailed in relation to specific psychiatric information, such as how a person with mania may present.

Step 4: Recruiting Examiners

There are a number of local consultant psychiatrists who are actively involved in teaching. They are supportive of the mock CASC and enthusiastic about examining stations. After the stations have been devised, consultants are invited to examine based on their areas of expertise. Higher trainees with particular interest in education are then asked to examine any remaining stations. Candidate instructions and actor’s notes are circulated to examiners in advance (figure 2). A simple guide to the mock exam is also sent to any new examiners. As we use the same marking scheme for each station, it is down to the experience of the examiner to consider whether the candidate has addressed the specific tasks appropriately.

Figure 2. Station template

Step 5: The Day of the Mock Exam

The higher trainee coordinators arrive at least 1.5 hours prior to the start time to set up the venue. Examiners, actors and candidates are asked to arrive 15-30 minutes before the scheduled start time. Each group is briefed on the exam format and given the opportunity to ask questions. Actors and examiners are shown to their stations and allowed time to discuss them. Candidates are provided with numbered labels to wear, for examiners to record on their marking sheets. The 4 candidates who will be starting later are asked to wait, while the others are shown to the examination rooms. They are shown which station they will be starting at, then queue in order at the door.

The mock exam coordinator stands where they can be heard by both rooms. There are 1 or 2 helpers in each room to guide the candidates around the circuit. The bell is rung to signify the start of the exam, the end of the 90 second preparation time (the start of each station), 1 minute warning and the end of each station. The candidates who were allocated to start later are brought into the circuit and shown to their station as the ‘end of station’ bell is rung, as this also signifies the start of the 90 second preparation time for the next station.

Marking schemes are collected and sorted during the break. Candidates are not kept separate from examiners, actors or each other. They are advised that they will get the most out of the afternoon if they don’t discuss the stations but this is ultimately their choice.

Examiners and actors return to their stations following the short break and candidates swap between circuits. Following the second round, there is another short break. Actors are excused at this point and most examiners remain for a feedback session. Marking schemes are collected, sorted and distributed to candidates. One room is re-set for group feedback. Examiners are thanked for their time and each is asked in turn for general feedback, hints and tips on their station (figure 3).

Figure 3. Mock CASC timing

Overcoming Potential Problems

Examiners

Our examiners are all either higher trainee or consultant psychiatrists. It is therefore possible that unforeseen circumstances mean that they may have to cancel at very short notice, attend late or not at all, or be called away during the mock exam. Each of these has happened over the past few years but has been easily managed by the extra higher trainee helpers stepping in to examine a station.

Actors

All of our actors have attended as planned. If a paid actor has to cancel at short notice, the agency will find a replacement. If a trainee actor did not attend, one of the higher trainee helpers could step in. Another potential problem which we have encountered is actors not performing as intended. This can be minimised by preparing clear instructions for actors, with examiners providing some direction if needed.

Quality control of stations

It is difficult to know how a station will work until it is used in the mock exam. To minimise the risk of problems, stations are checked and formatted before the exam. They are circulated to actors and examiners in advance to allow time for them to raise any concerns and clarify any uncertainties. Despite following these processes, there are some stations which appear unclear or do not run smoothly on the day of the mock exam. It is helpful to receive feedback from examiners, so that stations can be amended or avoided in future.

Timing

Our mock exam follows a very tight schedule. If the mock exam itself overruns, then fewer examiners may be able to remain to provide feedback. The higher trainee coordinator should keep time carefully during the day of the mock exam, particularly during break times, which are very brief. Support from other higher trainee helpers is essential for this, in working together to collect and organise marking sheets and guiding examiners, actors and candidates to stations. Late arriving examiners remain a potential problem due to their other commitments. We provide a sandwich lunch to our examiners prior to the exam, which helps with prompt attendance.

Venue

The venue we use is quite cramped and can become noisy. We have access to only 14 screens to divide the 16 stations so they are close together and those at the ends of the room are not fully enclosed. The screens are thin so only muffle the noise from neighbouring stations. These issues of space and noise are difficult to overcome. Trainees are warned in advance and aim to focus on their own station as much as possible.

Recruiting actors, examiners and candidates

To date, we have not experienced any problems in recruiting actors, examiners or trainee helpers. We have been able to fill all candidate places and often have a waiting list. If necessary, the mock exam could be run with fewer stations and still provide helpful practice for trainees. If resources were tight, trainees could be role-play actors for some or all of the stations.

Conclusion

We run a local mock exam annually due to continued demand from trainees. It takes significant time and effort to arrange but is good experience for the organiser and local trainees and consultants remain enthusiastic. The mock CASC in the West of Scotland puts a strong emphasis on providing feedback for trainees to work on. The provision of completed marking sheets on the day of the exam and the group feedback session help with this ethos. Our experience has shown that a mock CASC can be delivered locally, at a low cost, while still providing trainees with a realistic exam experience.

Introduction

Communicating effectively with patients and families is a vital component of high quality care. Studies have shown that patients feel excellent communication in consultations is vital for instilling confidence in the medical practitioner.^1,2 There is evidence that doctors are not meeting this fundamental need.³

Some consider it an ethical obligation of doctors to balance their training needs against providing optimal care for patients. It is well known that junior trainees have significant level of performance anxiety that translates through to their consultations.⁴

Simulation based training is now an integral part of postgraduate curriculum in training a variety of medical specialties in managing acute scenarios. As an education method it provides a controlled environment in which it is safe to learn from errors,⁵ and improves learner outcomes.⁶ Simulation has been shown to be a valid approximation of true clinical practice.⁷ It therefore allows trainees to reach higher levels of proficiency prior to embarking on real patient encounters.

Current Core Medical Trainees (i.e. junior doctors who have embarked on the first stage of physician training within England) in the London deanery are expected to be able to manage complex communication scenarios effectively prior to entering specialty training. This is demonstrated by requirements set out in the Core Medical Curriculum, as detailed in Box 1. Whilst significant emphasis is placed on communication skills training in basic scenarios at a medical student level, there is very little formal postgraduate communication skills training within this deanery and others.

Box 1: Excerpts from Core Medical Trainee curriculum

This deficit in training led us to conduct a survey exploring Core Trainees’ views regarding communication skills training in the London deanery. Findings from the survey are detailed in Box 2.

Box 2: Results from Core Trainee Survey

Method

We devised a pilot project using simulation to develop trainees’ competencies in advanced communication skills. After application to our local training board, we secured funding to run a number of sessions for core medical trainees within the London area.

The objectives of our pilot project were to provide experience of realistic communication based scenarios in a structured and safe environment to core trainees; provide feedback on trainees’ communication styles and offer suggestions for improvement; improve confidence of trainees in difficult communication situations.

Each session was conducted in an afternoon session and candidates were divided into three groups of three trainees who would remain together for the entire session. We ran four sessions, with a total of 36 trainees. Each group was facilitated by a consultant or a higher trainee in either elderly or palliative care medicine, given our focus on resuscitation/end of life discussions and assessment of capacity. We employed three actors to rotate around each group performing a variety of roles including patients and relatives. With a total of six scenarios, each trainee had the opportunity to participate in at least two scenarios lasting approximately 15 minutes, with feedback thereafter for approximately 10 minutes.

The scenarios employed were based on personal experience of regularly occurring, challenging communication situations encountered in our own clinical practice. We created detailed scripts for the actors as well as corresponding clinical vignettes for the candidates.

The scenarios were:

• End-of-life discussion with a challenging family regarding a patient with end-stage dementia.
• Discussing resuscitation with a family opposed to do not attempt resuscitation (DNAR) regarding an acutely unwell patient with poor functional baseline.
• Discussing resuscitation with a young patient with metastatic cancer undergoing palliative chemotherapy who has little understanding of the terminal nature of the disease.
• Assessing mental capacity regarding discharge planning in a patient with mild to moderate dementia.
• Assessing mental capacity regarding treatment in a patient with moderate learning difficulties.
• Assessing mental capacity in a medically unwell patient with mental health issues who wishes to self discharge from the ward.

Box 3 outlines the session structure.

Box 3: Timetable for the session

Results

Written feedback was obtained from all participants by distributing a post-course evaluation form, with a 100% response rate. A number of areas were assessed via a Likert scale of 1 – 5, with 1 being ‘not at all’ and 5 being ‘very much’. 100% of trainees felt the content was useful and their knowledge/skills had increased. 100% felt more confident after the session and all trainees and facilitators felt this would be beneficial for medical trainees. A full breakdown of results is detailed in Table 1.

Table 1: Results from post-course feedback

The post-course feedback form allowed for free text feedback from participants, with some individual examples given below:

— “Realistic scenarios - good opportunity to experience them and get feedback in a safe environment, good practice of common communication problems”

— “It builds confidence in dealing with these situations and provides basis for building up ”

— “This work dealt with complicated cases and actors were not too easy which I liked. Good and unforgettable”

Discussion

With the European Working Timing Directive and resulting shorter working hours, gaining proficiency in a number of key skill areas is limited due to reduced patient encounters. A recurrent complaint among core medical trainees is the lack of observed clinical encounters that leads to individualised feedback.

Feedback from more experienced speciality practitioners was only one component of our attendees learning experience. They also benefited from personal practise in a non-threatening environment, observation of their colleagues communication styles and finally learning through reflection with their colleagues

This innovation has shown a clear benefit in amplifying the confidence and preparedness of our core medical trainees in approaching these higher level communication scenarios. Future directions include introducing quantitative assessments pre- and post- course to objectively demonstrate improved confidence and performance. Providing the course to trainees in other specialties as well as across the multidisciplinary team would also be beneficial given the universal requirement of healthcare professionals to communicate skilfully.

CASE REPORT

A 73 year old male retired civil servant with a background of spinal bulbar atrophy and hypertension presented to his General Practitioner (GP) for a routine health check.  He was taking bendroflumethiazide, propranolol, atorvastatin and aspirin.  His brother also has spinal bulbar atrophy.

The GP sent routine blood tests, which came back as follows: Haemoglobin 8.5 (13-17g/dL), Mean Cell Volume 84.9 (80-100fl), White Cell Count 3.4 (4-11 x10^9/L), Neutrophil Count 0.68 (2-8 x10^9/L), Platelets 19 (150-400 x10^9/L).  A random blood sugar reading was 18 (3.9-7.8mmol/L).  Renal function, bone profile and hepatic function tests were normal.  The General Practitioner referred the patient urgently to the local Haematology unit for further assessment. 

On further review the patient complained of tiredness but had had no infections or bleeding.  There were no night sweats or recent foreign travel.  Physical examination was unremarkable, with no lymphadenopathy or organomegaly.

A blood film showed marked anaemia with red cell anisopoikilocytosis, prominent tear drop cells and neutropenia with normal white cell morphology.  There were no platelet clumps.  A diagnostic investigation followed.

QUESTIONS

What are the differential diagnoses of pancytopenia and which causes are likely here given the findings on examination of the peripheral blood film?

• Infections - Viral infections including cytomegalovirus, hepatitis A-E, Epstein-Barr virus, Parvovirus B19 and non A-E hepatitis viruses can cause aplastic anaemia1.  The classical picture would be pancytopenia in a young patient who has recently had ‘slapped cheek syndrome’ from parvovirus B19 who has transient bone marrow aplasia.  Tropical infections such as visceral leishmania may cause pancytopenia, splenomegaly and a polyclonal rise in immunoglobulins2.  Overwhelming sepsis may also cause pancytopenia with a leucoerythroblastic blood film (myeloid precursors, nucleated red blood cells and tear drop red cells).  HIV is also an important cause of cytopenias.
• Medications - common medications may cause aplastic anaemia, such as chloramphenicol, azathioprine and sodium valproate.  The history in this case did not have any recent medications introduced.  The other very common cause of pancytopenia in modern practice would be in the context of chemotherapy.
• Bone marrow disorders - tear drop cells are a key finding and clue in this case.  They suggest an underlying bone marrow disorder and stress.  In the context of a known active malignancy they are nearly indicative of bony metastases.  Our patient did not have a known malignancy and there was nothing to suggest this on the history or physical examination, although in a man of this age metastatic prostate cancer should be considered.  Other bone marrow disorders that would need to be considered are acute leukaemia (which was the diagnosis here), myelodysplasia and myelofibrosis.  Splenomegaly would be especially significant in this case as it would be highly suggestive of myelofibrosis in combination with tear drop cells wit pancytopenia in an elderly patient3. 
• B12 and folate deficiency – this may cause pancytopenia, tear drop cells and leucoerythroblastic blood findings4&5.  The mean corpuscular volume in this case however is normal which would somewhat argue against B12 and folate deficiency, as well as the fact that there were no hypersegmented neutrophils seen on the blood film.  This cause is however very important given how it is easily reversible and treatable.
• Haemophagocytosis – this is a bone marrow manifestation of severe inflammation and is a manifestation of systemic disease6.  It has various causes including viruses (e.g. Epstein Barr virus), malignancy and autoimmune disease.  It should be considered in patients with prolonged fever, splenomegaly and cytopenias.  It is diagnosed by characteristic findings on bone marrow biopsy.
• Paroxysmal nocturnal haemoglobinuria – this is a triad of pancytopenia, thrombosis and haemolysis caused by a clonal stem cell disorder with loss of membrane proteins (e.g. CD55 and CD59) that prevent complement activation7. 
• Genetic disease – Fanconi anaemia is a rare autosomal recessive disease with progressive pancytopenia, malignancy and developmental delay.  It is caused be defects in DNA repair genes.  

The key finding in this case was tear drop cells on the blood film.  These are part of a leucoerythroblastic blood picture seen in bone marrow disease, malignant marrow infiltration, systemic illness and occasionally haematinic deficiency.  See above for why this is unlikely to be haematinic deficiency.  Although tear drop cells can occur in systemic illness such as severe infection, the history here was not in keeping with this.  The diagnoses remaining therefore are malignant bone marrow infiltration or a primary bone marrow disorder (myelodysplasia, acute leukaemia or myelofibrosis).  There were no features in the history pointing towards a metastatic malignancy and therefore primary bone marrow disorder is the most likely diagnosis.  The diagnosis was later established as acute myeloid leukaemia on bone marrow examination. 

What investigations would help to confirm or eliminate the possible diagnoses?

• Blood tests including a clotting screen, liver function tests, inflammatory markers and renal function shall help to exclude other systemic disease such as disseminated intravascular coagulation, sepsis, liver disease and thrombotic thrombocytopenic purpura which may all give rise to cytopenias.  Autoimmune screening may also suggest vasculitis which can cause cytopenias.
• Microbiology studies including virology tests (e.g. human immunodeficiency virus, Epstein Barr virus and hepatitis viruses) may also be requested as appropriate given the clinical scenario and findings.  Visceral leishmania should be tested for according to travel history and clinical likelihood.  Leishmania may be identified through serology and light microscopy (for amastigotes) or polymerase chain reaction of the bone marrow aspirate.  Tuberculosis could be cultured from the bone marrow is suspected. 
• Haematinics are a crucial test and the aim should be to try and withhold transfusion until these results are known in case they can easily be replaced thereby negating the need for blood products.  Remember that if haematinics are not tested before transfusion then the blood products will confound the tests results. 
• Bone marrow biopsy, including aspirate and trephine are a crucial investigation for morphological examination and microbiological testing if indicated.  This will distinguish the bone marrow disorders including acute leukaemia, myelofibrosis, bone marrow metastatic infiltration and myelodysplasia.  Haemophagocytic syndrome may also be suggested by bone marrow examination findings.
• Imaging if there is suspicion of an underlying malignancy (e.g. CT chest, abdomen and pelvis) and then further blood tests such as the prostate specific antigen.  Ultrasound could also be used to check for splenomegaly where clinical examination has not been conclusive.
• Medication review is vital as this may reveal the diagnosis (e.g. use of chloramphenicol) 
• Flow cytometry may be considered to investigate for an abnormal clone in the case of paroxysmal nocturnal haemoglobinuria and may be used on bone marrow samples to further evaluate the cells.

Unless a very clear cause for the pancytopenia is obvious (e.g. haematinic deficiency or malignant infiltration) then bone marrow examination is crucial for establishing a diagnosis.  This will also prevent inappropriate treatments being initiated.

What immediate management steps and advice would be given to this patient?

General measures for pancytopenia include blood product support.  Red cells and platelets can be given for symptomatic anaemia and bleeding.  There is no need to transfuse platelets in the patient if there are no signs of bleeding.  Alternatively he could also be treated with tranexamic acid as an alternative to avoiding risks associated with platelet transfusion.  Infection should be treated urgently.  Due to the neutropenia he should be advised to seek medical help if he develops a fever or sore throat.  He should urgently be followed up in clinic with the results and given the contact details for the haematology department in the interim period in case he develops any problems.

The specific treatments for pancytopenia rests on the exact cause found after investigation.  In this case the diagnosis was acute myeloid leukaemia arising from a background of myelodysplasia.  The treatment for acute myeloid leukaemia in general, with curative intent, would consist of induction chemotherapy with DA (daunorubicin and cytosine arabinoside) followed by consolidation with further chemotherapy, the type of which (e.g. high dose cytosine arabinoside or FLAG-Ida) would depend on the risk assessment of the disease and possible consideration of an allograft bone marrow transplant after consolidation.  Currently different approaches to consolidation chemotherapy, transplantation and small molecule inhibitors are being evaluated in clinical trial (e.g. AML 17 clinical trial).

The other options, in older more frail patients where high dose chemotherapy will be very toxic, are low dose palliative chemotherapy and support with transfusion.   

PATIENT OUTCOME

He has been supported with blood products (platelets and packed red cells for bleeding and anaemia respectively).  After discussion with him and his wife he has elected to have palliative chemotherapy with low dose cytosine arabinoside.  He will be seen regularly in the haematology clinic and day unit for review.  We do not suspect a link between the leukaemia and spinal bulbar atrophy.

Introduction:

Sleep is a fundamental part of our lives and about one-third of it is spent sleeping. Sleep deprivation has been linked with such high profile public disasters, as Chernobyl, the Challenger shuttle disaster and the nuclear meltdown at Three Mile Island. According to the US Highway Traffic Safety Administration, approx. 100,000 motor vehicle accidents are the result of driver’s drowsiness and fatigue¹. There is an association of sleep disorders with anxiety and depression which may be bidirectional. Patients with insomnia for 2 weeks or longer, without current depression are at increased risk of developing major depression. Both insomnia and hypersomnia are considered independent predictors of depression and anxiety^2.

Key Milestones in the Development of American Sleep Medicine:

The history of treatment of sleep disorders dates back to at least the use of opium as a hypnotic reported in ancient Egyptian text. Sleep medicine, however did not emerge as a distinct discipline until the 1970’s. Drs. Kleitman and Dement were significant early contributors to this field in the United States. In 1957 they first described Non Rapid Eye Movement (NREM) sleep and Rapid Eye Movement (REM) sleep and proposed the 4 stages of NREM sleep. In 1972 Dr. Dement, a Professor of Psychiatry and Behavioural Sciences at Stanford University School of Medicine, contributed to the establishment of the first sleep disorder centre in Stanford. After Stanford, other centres in New York, Texas, Ohio and Pennsylvania started providing sleep evaluations for which patients stayed in the centre overnight. The Association of Sleep Disorders Centre (ASDC) was established in 1975 and Dr. Dement served as its first president for12 years. In 1999 ASDC was renamed American Academy of Sleep Medicine (AASM). The first textbook of sleep medicine “Principles and Practice of Sleep Medicine” was published in 80’s. The journal SLEEP started in 1978. In 1998 the AASM commissioned the fellowship training committee to develop guidelines for sleep medicine fellowship training. The first two programmes to be granted formal accreditation were Stanford University in California and the Centre for Sleep and Wake in Montefiore Medical Centre, New York. The American Medical Association recognized sleep medicine as a specialty in 1996. In 2004 the Accreditation Council on Graduate Medical Education (ACGME) took over the fellowship accreditation process and approved a one year training programme ^1,3,4,5.

Sleep Medicine training in Europe:

Unlike United States, there are no formal sleep medicine training programmes or qualification in the United Kingdom or Europe. Sleep medicine is restricted to a small group of respiratory physicians with a special interest in sleep medicine. Psychiatry trainees are exposed to very little formal teaching in sleep medicine. However in the last 3 years the neuropsychiatry section of the Royal College of Psychiatrists of the United Kingdom has formed the “sleep working group” under the leadership of Dr. Hugh Selsick, this group is responsible for increasing awareness of sleep medicine among British psychiatrists, by emphasizing the importance of sleep medicine in psychiatric practice and encouraging psychiatrists to contribute to the field of sleep medicine. This group has developed a competency based curriculum that incorporates the training of sleep medicine into the psychiatry curriculum, to organize sleep medicine symposia at annual conferences of the Royal College and to develop professional training (CPD) modules for psychiatrists. British Sleep Society is another forum that brings together physicians from various backgrounds interested in sleep medicine. Royal Society of Medicine also has a sleep medicine section which organizes various conferences. There are two, week long courses on sleep medicine, the Edinburgh and Cambridge courses. Recently the University of Glasgow started a Master’s of Science (MSc) in behavioural sleep medicine program for healthcare providers working in Scotland, the rest of the United Kingdom and Europe ^{6, 7, 8, 9}. There is a trans-European move to start a formal sleep medicine certification similar to what we have in the United States. European Sleep Research Society (ESRC), a professional body of sleep scientists in Europe responsible for promoting sleep research and sleep medicine is starting its “first ESRS certification examination” in sleep medicine; this examination is scheduled to take place on September 4^th, 2012 at the 21^st Congress of the European Sleep Research Society in Paris. Since there are no formal training programmes this will be for those without formal training ¹⁰.

Psychiatry and Sleep:

Asking about the patient’s sleep is an integral part of a psychiatric consultation. Almost all the medication that psychiatrists prescribe has an effect on sleep architecture. Some psychiatric medications are used to treat sleep disorders and others can cause sleep disorders like Restless Legs Syndrome and PMLD. Understanding sleep can help us understand the mechanism of psychiatric illness. Many psychiatric disorders have comorbid sleep disorders and several behavioural therapies have been used successfully for the treatment of sleep disorders. There is bidirectional association between sleep disorders and psychiatric disorders. With the growing population of military soldiers returning from Iraq and Afghanistan with post-traumatic stress disorder, sleep problems and depression, there is an increased need for psychiatrists who possess knowledge in both sleep disorders and comorbid psychiatric illness. Psychiatrists have a distinct advantage dealing with sleep disorders and can bring those skills to sleep medicine.

Are psychiatrists attracted towards sleep medicine? The answer is yes. In the recent years we have seen an increased interest among psychiatry trainees for a sleep fellowship in United States. In recognition of behavioural consequences of sleep problems and multidisciplinary approach in sleep disorders, fellowship programmes are increasingly taking applicants from various backgrounds and not just pulmonology and neurology. Many psychiatry trainees are choosing a sleep medicine elective earlier in residency. Currently there are more than 710 accredited sleep centres in the United States. Many major university medical centres have a one year fellowship programme accepting applications from physicians from various backgrounds including Psychiatry, Neurology, Internal Medicine, Pulmonology, Paediatrics, ENT and Anaesthesia ¹. There are more than 24 AGME approved sleep medicine fellowship programmes in the United States ¹¹. New fellowship programmes are being opened at the University of Kansas Medical Centre and the University of Texas Health Sciences Centre, San Antonio.

Conclusion:

Sleep medicine is a new and exciting field of medicine with potential to grow in future. It’s a multidisciplinary field. American sleep medicine has evolved greatly over the last 30 years and there appears to be much to learn from the American model. There is a need for the psychiatry training programs both in the United States and the Europe to encourage and prepare their trainees to consider training in sleep medicine. Psychiatry trainees in the United States interested in sleep medicine should speak with their programme directors early in their residency training to register their interest and residents should also contact the local sleep centre for more advice. Each year American Academy of Sleep Medicine (AASM) accepts 10 international physicians for its 4 week mini-fellowship programme. Three weeks of the fellowship are spent at an AASM-accredited U.S sleep centre with their last week of the fellowship spent at the annual SLEEP conference. A certificate of training is issued at the end of the mini fellowship ¹².

Background:

Controlled teaching environment can be provided to undergraduate medical students for learning certain basic clinical skills through using manikins or models before they have to perform them on real patients. Many medical schools in the United Kingdom now have clinical skills laboratories which are equipped with a large host of such learning resources. Many medical schools promote their clinical laboratories and have dedicated lead consultants to teach, monitor and develop clinical skills. Furthermore, a wide variety of skills can be taught in these laboratories. For example, the University of Leeds Medical school offers teaching to second year undergraduate medical students in basic life support, vital signs, injections, blood glucose monitoring, cannulation and venepuncture while third year medical students are taught fundoscopy, rectal examination, urinary bladder catheterisation, doing an ECG and examination of the breast. Similarly, simulators have also been used in postgraduate medical teaching, for example, Colonoscopy simulators have been used to calculate efficiency ratio of learners. ¹

However not all places in the world have clinical skills laboratories. Alternatively, some institutions teach the undergraduate medical students various basic skills in clinical supervised settings before they take up their first job as physicians. Some have assessed the level of training that their institutions have thus offered and tried to improve upon deficits. Mario Sicaja et al ² from Zagreb University evaluated 252 students using a questionnaire asking the students to self assess their abilities on nine groups of skills and asked 129 faculty teachers to simultaneously assess the minimum necessary level of skills they expected from the graduating students. They concluded that the teachers expected higher level of clinical skills from students than that assessed by the students. Similarly, in postgraduate teaching, the students’ learning needs have been assessed by determining the difference in expectation of trainers and the trainees. ³

Effectiveness of basic clinical skills training programmes has been documented and it has been suggested that longitudinal skills training offers superior preparation for abilities during the clerkship ⁴. It has also been suggested that whereas students from medical schools using traditional curriculum may not differ in their knowledge based performance, (demonstrated by Multiple Clinical Questions i.e. MCQ scores) from students at medical schools with clinical skills training, the later perform better on clinical examination (measured by Objective Structured Clinical Examination i.e. OSCE). ⁵

However, in many other medical schools worldwide, which implement the traditional undergraduate medical curriculum, there are no clinical skills teaching sessions for undergraduate medical students. The students get to learn this first time when they are doing internship and are in direct contact with the patients. It was the same situation in Liaquat University of Medical and Health Sciences (LUMHS) in Hyderabad, Pakistan. This is a large medical school which is based in the second largest city of Sindh province of Pakistan. The first author was invited from United Kingdom to review and advise on the undergraduate medical curriculum at LUMHS. The professor of plastic surgery (second author) had started to run a voluntary clinical skills course in his department covering some general basic clinical skills and provided his data to the first author for analysis and review.

This study was devised to analyse the views of participating students regarding the course and determine their learning needs. Based on the learning needs, one could identify which resources are needed and what the University should aim to provide.  Furthermore, there are no such published studies from Pakistan. This study was aimed at providing scientific information on the learning needs of undergraduate medical students from the developing world, which may be deemed to be different from the medical students in the western world.

Methods:

All medical students from fourth and final year at LUMHS were invited to attend four weeks of clinical skills course at the plastic surgery department voluntarily. The students had to attend the department after their normal working hours. There were dedicated junior doctors in the department who were given the responsibility to teach the attendees hands on clinical skills in a structured manner. The skills included  history taking, organising blood tests, vene-puncture, giving intravenous and intra-muscular injections, intravenous cannulation, urinary bladder catheterisation, passing naso-gastric tube, dressing of surgical wounds, basic pre-operative assessment, basic post-operative assessment including haemo-dynamic stability, surgical theatre mannerism, principles of sterilization, identification of common surgical instruments and equipment and identification of types of drugs used in anaesthesia. The students were provided a questionnaire asking for feedback on the course which they had to fill at the end. The study was approved by the University Research and Ethics Committee. The data was computerised and statistically analysed using a statistical package. It involved all students who went through the course during consecutive sixteen months commencing from October 2008 and ending in January 2010.

Results:

90 students were recruited to the study. Students were from both sexes and both fourth year and final year. There were 32 male (35.6%) and 58 female (64.4%) students. Of the total 90 students, 62 (68.9%) were from 4^th year while 28 (31.1%) students were from final year. They were all volunteers who were willing to attend the course after their normal working hours and were allocated seats on a first come first serve basis. No student was refused entry to the course and all participants were provided questionnaire on feedback at the time of completion of the course. The response rate was 100% although this may be because students were actively encouraged by the teaching staff to ensure that feedback questionnaires were filled in. 

History taking and laboratory investigations were deemed least important by students, perhaps because these are taught to them during normal attachments in all wards for clinical teaching.

The Friedman mean rank was highest for catheterisation of urinary bladder (11.66) and passing of a naso-gastric tube (12.44). The students felt the greatest need to learn these two basic clinical skills perhaps because they are not taught elsewhere. This was followed by anaesthesia, sterilisation and passing an intravenous cannulation. The students ranked learning of the learning of the following skills  in the middle: giving injections, taking blood, providing pre or post-operative care and being able to identify surgical instruments. Taking history and arranging laboratory investigations were both ranked the lowest at 6.22. The Friedman asymptotic significance was high (p<0.000). Despite being a good sample size, Monte Carlo significance at confidence interval of 99% was very high (p<000.0). Table below summarises the statistics

Our study has shown that undergraduate medical students from the developing world greatly value a basic clinical skills course, and are particularly keen on being taught naso-gastric intubation and urinary bladder catheterisation. They seem to get enough exposure in the wards on history taking and arranging laboratory tests, but identify learning needs in other clinical skills.

This study is limited to data collection from one large medical university, but the sample size has been large, observation has been over a period of one year, statistical significance has been very high and response rate has been extremely good. The teaching staff actively encouraged the students to fill the feedback questionnaires, and this could arguably lead to some response bias.

There are no such previous studies from Pakistan to compare our findings with. This study therefore can make a good baseline for local institutions to further develop and build upon. Roy Remmen’s group compared four medical schools on clinical skills of students, and demonstrated positive effect of both longitudinal skill training as well as utilisation of problem based approach in these skill courses. Our study did not provide any longitudinal data and problem based learning approach was not utilised either. Our data is a cross sectional study.

There seem to be three levels of engagement in learning basic clinical skills. One side of the spectrum has structured teaching in clinical skills laboratories with simulation, models and manikins, while the other has no teaching of clinical skills at all, until the physician starts to work with real patients. In the middle is the model of teaching clinical skills on the wards, before graduating as doctors. The former model with clinical skills laboratories requires the most resource. Which model of teaching is adopted by any individual medical university may be dependant upon the local resources, as well as the demands of the local regulatory bodies.  During this study, we were able to realise the pattern of clinical skills teaching at some other medical universities in Pakistan, India and Bangladesh as random examples of southeast Asia. We learned that most institutions in this part of the world do not undertake any formal clinical skills teaching, and certainly there are hardly any clinical skills laboratories. This voluntary attempt by the professor of plastic surgery at LUMHS is therefore commendable. 

This study has also identified the keenness of students to learn some specific skills through such courses prior to graduation. With a move to more globalisation of medical protocols and guidelines, a greater uniformity should also emerge in the ways in which doctors in the east or the west hemisphere of the world learn medical knowledge, attitudes and skills. There may thus be need for researchers in medical education to encourage and push for adoption of clinical skills teaching courses prior to medical graduation in the developing world.

Furthermore this study has yet again reiterated that student’s views should form a key part in the curriculum design when considering development of a clinical skills course, and resources should be geared to meet these learning needs of students.