DR BRIAN FITZMAURICE Department of Psychiatry Trinity College, Dublin b.fitzmaurice@tcd.ie

1. Virtual Interviews for Students Interacting Online (VISIOn) - novel way of learning clinical skillsFitzmaurice, B., Armstrong, K., Rogers, C., Dagger, D., Gill, M. DR BRIAN FITZMAURICE Department of Psychiatry Trinity College, Dublin b.fitzmaurice@tcd.ie

2. Current VISIOn / ADAPT Team Dr Brian Fitzmaurice Katie Armstrong Dr Cathy Rogers Prof Michael Gill Psychiatry Health Informatics Psychiatry Psychiatry Dr Declan Dagger, & Conor Gaffney Dr Vinnie Wade, Director, Programmers, Computer Sciences (KDEG) Centre for Learning Technology

3. 7 Core Domains Global Essential Requirements in Medical Education (World Federation for Medical Education)

4. Importance of Learning Clinical Interview Skills • History Taking contributes 60 - 80% of data for diagnoses Relative contributions of History taking physical examination, and laboratory investigation to diagnosis in medical outpatients. Hampton JR et al, BMJ 1975;2:486 • Communication skills deteriorate during medical school Pfeiffer C, Madray H, Ardolini A, Willms J. Medical Education 1998:32:283-8 • Better Communication = Fewer Malpractice Cases Levinson W, Roter DL, MulloolyJP, Frankl RM. JAMA 1997;277:553-9 • Poor Communications skills assoc with complaints / litigation Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities Tamblyn, R, Abrahamowicz, M et al JAMA 2007;298:993-1001.

5. Importance of Learning Clinical Interview Skills My real concern is not whether you have failed, but whether you are content with your failure. Abraham Lincoln

6. Importance of Learning Clinical Interview Skills • Communication training has lasting benefit Maguire, P., Fairburn S, Fletcher C. BMJ 1986;292:1573-8 • Simulated Patients used in majority of Medical Colleges Medical School Objectives Project, Report III, (1999) Contemporary Issues in Medicine: Communication in Medicine, AAMC • TCD experience Simulated patients are expensive & logistics difficult

7. Where are the problems? Typical comments from survey about learning interview skills (before VISIOn I) “not enough opportunities for practice” “There was not a lot of opportunity to observe other doctors interviewing patients.” “easy to learn from a text book but much harder when you do it in person.” “Most useful learning method was being allowed to interview patients alone and in the video presentations”.

8. Where are the problems? The Specialist one who increasingly knows more and more about less and less until he knows almost everything about nothing

9. Required Learning • Knowledge: arrange, define, duplicate, label, list, memorize, name, order, recognize, relate, recall, repeat, reproduce state. • Comprehension: classify, describe, discuss, explain, express, identify, indicate, locate, recognize, report, restate, review, select, translate, • Application: apply, choose, demonstrate, dramatize, employ, illustrate, interpret, operate, practice, schedule, sketch, solve, use, write. • Analysis: analyze, appraise, calculate, categorize, compare, contrast, criticize, differentiate, discriminate, distinguish, examine, experiment, question, test. • Synthesis: arrange, assemble, collect, compose, construct, create, design, develop, formulate, manage, organize, plan, prepare, propose, set up, write. • Evaluation: appraise, argue, assess, attach, choose compare, defend estimate, judge, predict, rate, core, select, support, value, evaluate.

10. Required Learning Tell me, I’ll forget. Show me, I’ll remember. Involve me,
I’ll understand. Chinese proverb

11. Required Learning

12. Virtual Interviews for Students Interacting Online (VISIOn I)

13. Virtual Interviews for Students Interacting Online (VISIOn I) 65% used simulation more than once 45% spent longer than 1 hour using simulation 55 % felt they were “virtually” interviewing patient 100% more inclined to use internet for learning

14. Virtual Interviews for Students Interacting Online (VISIOn I) “What was useful for learning interviews skills in Psychiatry?”. Before VISIOn After VISIOn (n = 38) (n = 32) 1 Conducting interviews themselves 100% 100% 2.Video interviews of themselves/others 80% 78% 3.Observing interviews by doctors/other professionals 78% 74% 4.Books 72% 74% 5.Tutorials from doctors 71% 70% 6.Web based support 20% 76% “Need more simulations to give experience across many disorders”

15. Virtual Interviews for Students Interacting Online (VISIOn I) Study Double blind RCT of online simulator to teach communication skills to medical students

16. VISIOn I Study Control group receive identical online teaching package without online simulation available Simulator Group Control Group

17. VISIOn I Study

18. VISIOn I Study Comparisons between the 2 students groups on A. Assessor ratings of video recorded interviews with patients using: 1. Leicester Assessment Protocol (LAP) 2. Calgary-Cambridge Observation Guide 3. Harvard Medical School Medical Interview Scale B. Self rating of Confidence and Competence C. Self Assessment of Interview style/preferences

19. VISIOn I Study Data Collection nearing completion Analysis of early data show simulation group have: Higher competence scores (LAP) in videos Lower self ratings of confidence and competence More patient-centred approach

20. VISIOn I Study • Limitations • Only one simulation assessed • Other teaching techniques confounding • Self assessment of students own skills unreliable with overestimation of competence

21. VISIOn II • Unique collaboration with the Department of Computer Science • Grant funding (Enterprise Ireland Technology Development Fund) • More interviews and expansion of content • Tools to enable easier creation of simulations • www.simulatedinterviews.com

22. Creating the dialogue

23. Creating the dialogue

24. Greeting the patient with Depression

25. A virtual Interview

26. Select a question from a category

27. Our Manic Patient in full flight

28. Developing a rapport with our patient with Schizophrenia

30. Ask the experts how to interview…

31. Mental State Examination Quiz – question examples

32. VISIOn II Evaluation • Qualitative research – questionnaires on 18 medical students and focus group • 82% accessed the tool easily by logging on • Accessed the simulations 3 times on average, in hospital, trinity and at home • Average time spent on the simulator each time was 45 minutes • The average total time was 90 minutes (range 25minutes – 4 hours)

33. VISIOn II Evaluation • 76% felt it was a valid tool for learning communication skills • 65% felt it highlighted the different learning objectives and skills needed for interviews • 82% found the instructional material appropriate • 88% valued the glossary as extremely useful

34. VISIOn II Evaluation ‘better idea of how to approach questions and areas that are particularly sensitive’ ‘made me aware of phrasing appropriate questions’ ‘gave me a sense of the structured nature of an interview’ ‘also got to see the implications of different lines of questioning’

35. VISIOn II Evaluation ‘more cases of all the common disorders’ ‘include a random case with disorder not stated’ ‘show a model interview from start to finish’ ‘loved the MSE but some kind of further assessment at the end re your performance’

36. VISIOn II Evaluation Tell me, I’ll forget. Show me, I’ll remember. Involve me,
I’ll understand. Chinese proverb

37. VISIOn II Evaluation Irish Healthcare Awards 2007 Runner-up in “Best Use of IT” Category

38. Online Psychiatric Teaching for Developing Countries Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka Letter to Psychiatric Bulletin, Oct 2007 Fitzmaurice et al (Psychiatric Bulletin, June 2007, 31,218-220) highlight an important area in medical education, which is also relevant to psychiatric education in many developing countries. Even though the morbidity due to psychiatric illnesses is very high, there is a scarcity of qualified trainers in our part of the world…… Medical teachers in developing countries should think about incorporating online teaching and clinical interview skill training programmes in psychiatry as many medical schools have access to online teaching facilities. It may be feasible and cost effective even in resource poor countries.

39. Future role of Simulations

40. Ongoing work 6 Healthcare Communications Simulators can be used as: 1. Educational tool (University / Training Body) 2. eLearning tool / exam preparation (student) Need to be evaluated outside of our University environment • Doctors starting in Psychiatry (Spring 2007 / January 2008) • Other disciplines (Nursing Students Autumn 2007) • Other Universities (University of Edinburgh)

41. Acknowledgements Department of Psychiatry : Prof Brian Lawlor Prof Michael Fitzgerald Prof Anthony Clare Dr Anthony Bates Dr Gary Donoghue Centre for Learning Technology : Valerie Carroll, Catherine Kane, Theresa Logan Phelan Dr Barbara Dooley, University College, Dublin (Statistical Advice) Andrew Bates, Neil Peirce (AV work) Maggie Armstrong (Artwork) Kate Perry, Celine Mullins, Paul Gaskor (Acting)

42. Acknowledgements Funding for VISIOn from: Trinity College, Dublin Senior Lecturer’s Office Centre for Academic Practice and Student Learning (CAPSL) School of Medicine and Health Sciences Janssen-Cilag (Ireland & UK) Ltd Astra Zeneca (Ireland) Ltd Eli Lilly (Ireland) Ltd Pfizer (Ireland) Ltd Follow on project ADAPT: Enterprise Ireland

43. Further information b.fitzmaurice@tcd.ie Katie Armstrong,VISIOn Project Co-ordinator Katie.Armstrong@tcd.ie Department of Psychiatry, Trinity Centre for Health Sciences St James’s Hospital, Dublin 8, Ireland Dr Declan Dagger, ADAPT Project Manager Declan.Dagger@cs.tcd.ie Knowledge and Data Engineering Group (KDEG) Department of Computer Science, TCD Telephone:+353 1 896 1335