What features of simulated patients are valued in teaching the psychiatric interview?

Musa Basseer Sami 
Jalil-Ahmad Ali Sharif 
Elizabeth Raybould Centre, Dartford

Reflection on existing practice

Simulation in teaching the psychiatric interview has become increasingly important over the recent past(1). Although traditionally taught through clinical exposure of ‘real patients’ and similarly assessed in the real world example of the ‘long’ and ‘short’ cases, several weaknesses were identified in this method of teaching and assessment (2). Clinical exposure maybe limited to a certain type of case and thus selectively sample the curriculum, thus failing to give a broad overview. Similarly there maybe inequity between trainees or students who may have different exposures and thus different training experience. Consequently simulated patients are able to deal with both of these problems: the use of simulated patients allows for a broad sampling of the curriculum. Furthermore the use of simulated patients allows for the standardisation of scenarios, thus reducing inequalities in exposure and clinical learning (3).

As a Higher Specialist Trainee in Psychiatry one of us (MBS) been extensively involved in the use of simulated patients for teaching and ‘mock exam’ assessment purposes. I have organised seven workshop days since August 2013- January 2016, which have benefitted around 60 postgraduate psychiatry trainees and 40 undergraduate students. Both workshops have taken slightly different forms: with postgraduate use of simulated patients being for the mock CASC exam (Clinical Assessment of Skills and Competencies), the high-stakes final membership exam of the Royal College of Psychiatry; whereas the undergraduate workshops have taken a more relaxed approach in order to give an introduction to the common psychiatric presentations. However what is common in both of these scenarios is (1) the use of Simulated patients (i.e. actors playing a patient with a psychiatric condition or relative) and (2) a form of formative assessment with feedback to the student or trainee on how to improve in the future. This is a well-recognised model of experiential learning often used in one-to-one or small group settings to teach sometimes complex communication skills in a safe environment (4).  Involvement in these workshops has several components – including writing the scenarios, liaising with and booking the actors, drawing up the session plan, organising the candidates, examiners and actors and acted as an examiner.

As a Core Trainee in Psychiatry one of us (JAAS) has been a participant in three workshops as a trainee and learner. The workshops I participated in have been tailored for the CASC examination.

Both students and postgraduate trainees have consistently given feedback to show they value these sessions and particularly the feedback they receive from actors and exposure to realistic situations. Overall feedback from student and trainee evaluation, although often strongly positive and very often complimentary has provided limited utility in guidance regarding how to improve or modify such workshops in the future. There is a general consensus of how students particularly value feedback given in the post-scenario briefing. Anecdotally from our observations as clinical teachers, the use of simulated patients for psychiatric teaching purposes can ultimately be a hugely valued experience.  We wish to tease out in more detail the reasons for this. This will enable us to apply research findings to current practice to ensure the maximum educational value for the workshops, both undergraduate and postgraduate.

Introduction and background

Consequently this literature review aimed to determine: which particular elements of using simulated patients are valuable in the teaching of the psychiatric interview.

By simulated or standardised patient the literature review meant: a trained participant who is trained to portray a role for the educational purpose of the session (3). This was differentiated from role-play where an untrained individual (usually a fellow student) takes on the role (3). This literature review therefore did not look at role play between students as the interactions between students are likely to be different to roles portrayed with an attempt at psychological fidelity. By psychiatric interview the author meant any aspect of the interview including history taking or communication skills.

This literature review examined both postgraduate and undergraduate contexts as this was relevant to the author’s teaching practice.  Within the overall question stated above – several questions arise: for example (1) what is the role of simulated patients in teaching the psychiatric interview (2) does the fidelity of the simulated experience effect the value that trainees place on the experience, (3) are there optimal ways of structuring the session and (4) what is the best way to give feedback to the student or trainee. The literature review attempted to answer these sub-questions separately in order to build an overall picture.

Only evidence from original studies including feedback, evaluation or research was included in this review. The review avoided opinion pieces or discursive commentaries in order to ensure focus on the evidence to date.

Full text articles in English: (“simulated patient” OR “standardised patient” OR actor) AND (psych* OR Mental State Exam*) AND (education OR feedback) were searched in Pubmed (Medline Database) and PsychInfo on 11th March 2015.  Abstracts were screened against the following inclusion criteria: (i) articles involving original feedback, evaluation or research (ii) regarding any aspect of psychiatric interview, and (iii) including both postgraduate and undergraduate psychiatric teaching.  Consequently the literature search identified 6 papers for review. These are discussed in further detail below.

Critical literature review

What is the role of the simulated patient interview to teach psychiatric clinical skills?

From an overview of the included papers it is clear that there are a wide variety

of uses for the use of simulated patients in teaching the psychiatric interview including (i) developing skills in interview (ii) exposure to difficult to access clinical scenarios and (iii) use in assessment.

Simulated patients were used to develop a variety of skills: history taking skills (5); improving skills in informed consent (6); and risk assessment (7). All three papers reported positive results correlating use of standardised patients with positive feedback. However, this must be interpreted with caution: as the design of all three studies were pre-session and post-session self-reported confidence measures of the learners. It could be argued that teaching is always likely to improve self-reported confidence measures and such improvement does not measure objectively acquisition of the desired skill. Furthermore only one study reported the benefits in comparison to a control group of students who had “teaching as usual” (7).

A further use of simulated patient interview is developing clinical exposure to rare or potentially distressing situations in a safe environment. The simulated patient interview has thus been used in teaching a rare experience in refugee medicine (8). This was undertaken remotely through web-conference by 10 Swedish medical students with a simulated refugee from Iraq who had recently arrived in Australia. A follow-up debriefing session focussed on students response to the emotional distress of the trauma. This is the only study which compared the experience of interviewing a simulated with a real patient, with a safe environment provided through simulation:

Students reported that they were deeply moved by the patients’ (real and simulated) trauma histories. They also reported that they felt less inhibited n questioning the simulated patient rather than the real patient.

The use of simulated patients also has a role in assessment: one study used a simulated patient interview to assess and compare differential performance of International Medical Graduates performed in comparison to US Medical Graduates in eliciting a diagnosis of clinical depression (9). A further paper also looked at performance assessment of communications skills of 1st year vs. 5th year medical students in a simulated scenario design to test skills in a psycho-social assessment (10). Yet both papers assumed that the use of simulated patients was an adequate assessment method for their study – neither showed validity nor reliability measures for their chosen method of assessment using simulation.

Does the fidelity of the simulated experience effect the value that trainees place on the experience?

The study of refugee psychiatry by Ekblad and colleagues, noted above, was the only study which directly compared learners’ experience of simulated with a real patient. As noted from the quote above, the focus group noted that both scenarios were life-like and emotionally involving. This is despite the non-use of a professional actor, rather an expert professional member of teaching faculty was used to play the simulated patient. Similarly learners report positive feedback with both professional actors (7) as well as trained professionals such as psychiatric nurses (5) as the simulated patients. In the latter study, psychiatric nurses were used as simulated patients having received 1 hour training on simulation prior to the session in a low-resource setting in Zimbabwe. 7 out of 23 medical students who undertook the session noted in the end of session feedback they would have preferred real patients with several commenting that the nurses gave them answers too readily. It thus would appear that acting skills are an important constituent to effective teaching design, although there are no direct head to head trials of professional versus lay actors to more effectively answer this question.

Are there optimal ways of structuring the session?

Different authors have taken different approaches to structuring sessions with simulated patients. One model is to provide learners undertake the interviewing sessions with simulated patients followed by debriefing (5,7). The simulated patient activity thus becomes small group teaching of 4-6 learners in each scenario. This appears based on Kolb’s experiential learning cycle – learning through doing with reflection and consequent development upon the experience (11). A variation on this model has been described where the clinical teacher undertook the interview with students observing and asking follow-up questions used in the trauma interview of a psychiatric patient (8). It is likely that this contributed to the safe environment that students reported in the session. An alternative model was described in Massachusetts where the simulated patient interview task (gaining consent for psychotropic medication prescribing) was inbuilt into a computer simulation (6). The psychiatric resident undertook the scenario, clicking on the relevant options which appeared on the computer screen as to how he would proceed with the interview. The actor was interviewed by a simulated doctor onscreen with pre-recorded options shown depending on the learner’s choices. Candidates reported increased confidence in skills of informed consent and prescribing skills after the session. It is not possible to directly compare the effectiveness of these teaching approaches as there are no direct head to head studies.

There are differences in how much teaching to deliver pre-session. Whereas Piette and colleagues provided a didactic lecture to leaners, Fiedorowicz et al had embedded these teaching sessions into the curriculum and thus did not provide extra material pre-session. In the scenario of refugee psychiatry learners received pre-course material and had attended a four day workshop in transcultural psychiatry before exposure to the simulated patient. In the case of simulated patient teaching with junior students, learners were taken to meet the actors before the session, which resulted in reported reductions of anxiety during the session (10). Again it is not possible to undertake a direct comparison as there are no direct or head to head studies of one method versus another.

What is the best way to give feedback to the student or trainee

Two studies appeared to have been used as summative assessments and evaluations of different groups of learners and did not report providing any feedback to learners (9,10). All other studies reported feedback although the methodology varied. Medical students were provided feedback in a risk assessment workshop by group feedback, discussion and re-rehearsal (7). The Zimbabwean study followed a similar structure, with students also involved in feedback although re-rehearsal was not undertaken (5). It is possible that immediate re-rehearsal after feedback has an educational advantage as it allows for consolidation of learning, however no direct data was provided in order to establish this. In the psychiatry interview of a refugee feedback was undertaken through debriefing of the students to build on their learning from clinical exposure rather than to critique their performance (8). The computer simulation allowed for feedback linked to students performance directly (i.e. areas they had missed out in the algorithm) and was able to provide immediate personalised feedback with links to resources for further learning. However it is not possible to draw conclusions about the best method of feedback in the absence of direct comparisons.

Conclusions

Simulated patients can be widely applied to teaching and assessing various part of the psychiatric interview. There is a variety of applications and use of simulated patients within a session. Participants consistently report increased confidence in skills after a session with simulated patients. However there is limited evidence base to establish whether the use of simulated patients objectively develops skills, or acts as a valid assessment tool. This does not mean that the use of simulated patients do not, but more specifically that there are areas which need to be researched more rigorously, using objective measures of skill acquisition in the context of learning, and reliability and validity in the context of assessment.

Thus although the current literature allows us to surmise general directions in terms of educational features of using simulated patients, specific data informing specifically the benefits of each component of using simulated patients is lacking.

Similarly there are no direct measures of fidelity employed in any of the studies included in the literature review and limited conclusions can be drawn from this. Given the results from Ekbald et al, it does not however appear that knowing the patient is simulated or an actor necessarily detracts from the value trainees experience through simulation. This is a single study of a simulated and real patient and requires further replication.

Taken overall there appear to be variations in how much exposure to give learners to the simulated patients and whether learners should take the lead in interview. This appears to be linked with the aim of the task at hand – developing interview skills (such as in our role) appears to require more direct exposure, whereas understanding clinical narrative can be facilitated through a teacher-lead interview. Developing clinical reasoning can be undertaken through a more remote method of computer-based simulation.

This idea that the aims of the learning session will dictate the exact form of the simulated patient session is also applicable to the pre-session preparation provided and provision of feedback. For example the computer based simulation teaching an algorithmic approach to informed consent will more clearly identify areas specific areas missed in the algorithm and feed this back to the learner on screen, whereas if the task is development of interview skills, this prima facie would be better provided in a small group feedback.

Virtual Patients or Virtual Human Agents are an emerging technology in simulation based teaching(12), and can also be useful in the psychiatric settings, these could address and reduce bias by actor or trainers against the trainee, however limitations in the usage of virtual patients for educational purposes will likely be homogenous to simulated patients as mentioned below.  

Additional feedback can be provided through video recording the simulated doctor-trainee patient/actor interaction, the recorded video is a useful multifaceted reflection tool, with the help of the trainer and peer feedback.(13) Video Recording Technology through mobile phones has become ubiquitous, and the access enables retrospective analysis of the interview, the interpersonal processes, difficult communication and the overall performance for the specific task laid out pre-session. (14,15)

Simulated patients are helpful in the acquisition or testing of specific skills in the psychiatric interview. However criticism of simulation includes difficulties in assessing interpersonal processes, concerns are surrounding the hyper-reality of the simulated empathy and emotional content between the doctor-learner and simulated patient-actor as well as the simulated transference and counter-transference. This Hyper-reality could potentially hinder building empathic alliances with real patients presenting with challenging symptomatology, where communication requires adjusting of empathic reactions and psychodynamic processes to aid in discrimination of distinct character pathology.(16,17)

This view needs to be further established through studies comparing various components of simulated patient interventions to delineate these factors in more detail.

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