Diagnosing Anxiety: A Standardized Patient Telemedicine Case for Clerkship Students

This Standardized Patient simulation was designed to assess the ability of 3rd year medical students to apply skills attained on their psychiatry clerkship through direct patient care. Originally, this formative assessment was formatted as a standard face to face OSCE but transitioned to a telemedicine session eight months prior to the start of the pandemic. This was fortuitous as it served as a model of a fully functioning and vetted assessment prior to the COVID-19 pandemic and the need to temporarily halt in person educational activities.

The CMU psychiatry clerkship is a four-week experience. Students complete the telemedicine assessment sessions during the second week of the block, after limited experience working with patients but after receiving preceptor guidance on conducing a patient history, assessment, and treatment plan. Students are provided with technical instructions prior to the telemedicine encounter to lessen anxiety associated with the virtual format. On the day of the assessments, students complete two telemedicine encounters and complete a clinical note for each. Feedback is received during mid-clerkship evaluations where students are provided information on their interview style, history obtained, and delivery of treatment plan. Student documentation is also reviewed, and feedback is provided on completeness, organization, mental status examination (MSE) and treatment plans. This feedback allows students to utilize this information provided and integrate it into the remainder of their patient encounters and evaluations to improve their skills through the remaining weeks of the clerkship. CMED third year medical students complete their psychiatry rotation at one of several clinical sites distributed across Michigan. In order to conduct the OSCE, students had been required to travel, between 1- 4 hours to our simulation lab. Student concerns were assessed with the disruption travel time was causing to their clinical training, posing a greater burden for those students at branch campuses. The requirement for students to travel to one of our two simulation centers to complete the OSCE was negatively impacting student learning. To minimize the need for student travel, we chose to use Microsoft Teams as the virtual platform for the telehealth encounter, but there are many viable options that could be adopted. Students are able to log into the virtual encounter remotely from their assigned locations. Standardized Patients (SPs) routinely report to the simulation lab to join the telehealth session. However, during mandated state closures, SPs joined remotely from their homes. Medical school simulation staff were on-site, enabling the recording of the virtual encounter and to troubleshoot any issues. This enabled easy access to videos and evaluations for the Course Director to review remotely.

Pre-session materials uploaded for students on their learning management system include a simulation session directions and technical instructions for students to access the week prior to the encounter (Appendix B and C). The session directions detail the materials and hardware students will need to utilize, as well as the timing and structure of the session. The technical instructions guide student in how to utilize teams, gives them a link to test and prepare prior, and IT resources if they experience technical difficulties. When students enter the virtual Teams meeting on the day of their sessions, they receive verbal session instructions (Appendix D) from simulation staff in their break-out room. The share screen feature is utilized to allow students to read door note (Appendix E) information before their Standardized Patient enters the room. Students are given 2 minutes for door note review, 35 minutes to interview the SP, then 35 minutes to complete the clinical note on their Learning Management System (Appendix I). Students complete 2 SP encounters each and receive written feedback from their SP utilizing a RUCIS checklist. Following their encounter, the course director provides feedback in their mid-clerkship evaluations to provide feedback on their patient encounter and clinical note writing.

This simulation was constructed to run with a minimum of staff required. The cases are offset, allowing one simulation specialist to deliver student instructions prior to starting the recording of the encounter. Faculty has access to the recorded videos and clinical notes to review to deliver feedback to students at a later time. Standardized Patients were selected based on the ability to provide an accurate portrayal of symptoms, the ability to deliver unscripted lines within the bounds of the patient they are portraying, and the ability to deliver patient-centered feedback. Online videos were utilized for training when these cases were first introduced to showcase patient manifestation of psychological symptoms. Later training utilized captured videos of current SPs within the role. A case was developed to utilize in training as well with background information provided to SPs. The clerkship director provides formative feedback to each student after reviewing the simulation video and documentation provided for each of the patient encounters. For the interview portion of the encounter, the clerkship director is looking for the student’s ability to build rapport, provide empathic responses, obtain history, screen for necessary psychiatric disorders, and provide appropriate treatment plans. The documentation is reviewed to assess student’s ability to synthesize information obtained during patient encounter in and organized and complete way. Students ability to complete a thorough mental status examination (MSE) and treatment plan/formulation is also assessed for in reviewing of the documentation. Feedback on these different elements are provided to the students during their mid- clerkship evaluations.

Approximately 104 third year medical students have completed this educational activity in the last two years. Prior classes completed this onsite in a face-to-face encounter with Standardized Patients. Converting these sessions to the virtual environment has given students experience in the growing trend toward telemedicine that has been steadily increasing over time within clinical rotations. It has additionally allowed sessions to be conducted with less facilitators to run and record sessions, eliminating the need for additional human resource elements that existed prior for in-person sessions.