The Effectiveness of Online Experiential Learning in a Psychiatry Clerkship.

OBJECTIVE: The Uniformed Services University of the Health Sciences 5-week psychiatry clerkship educates about 180 students a year at sites around the USA. In 2017, weekly in-person experiential learning sessions were implemented for local students and resulted in improved performance in several end-of-clerkship Objective Structured Clinical Examination (OSCE) skills as compared to distant learners who did not receive these sessions. The difference in performance (~ 10%) highlighted a need to provide comparable training for distant learners. Providing in-person, repeated simulated experiential training at multiple distant sites was not practical, requiring development of a novel online approach. METHODS: Students at all four distant sites over 2 years (n = 180) participated in five weekly synchronous online experiential learning sessions, while local students (n = 180) received five weekly in-person experiential learning sessions. Tele-simulation used the same curriculum, centralized faculty, and standardized patients as the in-person iterations. Overall end-of-clerkship OSCE performance was compared for learners receiving online versus in-person experiential learning for non-inferiority. Specific skills were compared to receiving no experiential learning. RESULTS: Overall OSCE performance was non-inferior for students who received synchronous online as compared to in-person experiential learning. Performance on each skill other than communication improved significantly when comparing students who received online versus no experiential learning (p < 0.05). CONCLUSIONS: The use of weekly online experiential learning to enhance clinical skills is comparable to in-person efforts. Virtual, simulated, synchronous experiential learning provides a feasible and scalable platform for training complex clinical skills to clerkship students, a critical capability given the impact the pandemic has had on clinical training.

Psychotropic Medication Informed Consent: A Cross-Specialty Role-Playing Skill Builder.

Introduction: Obtaining informed consent (IC) is an essential medical practice. Utilization of IC role-playing training with medication study cards and self-peer-supervisor review should improve student fund of knowledge and strengthen IC skills for clerkship-level medical students. Methods: Between 2017 and 2020, approximately 555 clerkship medical students used our formative role-playing exercise tools. Students independently prepared psychotropic medication study cards and role-played IC during group didactics. Peer and supervisor reviews were not recorded but were discussed as a group. Students completed routine anonymous postclerkship surveys regarding the IC exercise. An enhanced IC curriculum was deployed in 2020, adding a training video and peer/supervisor feedback form. Student feedback and specialty shelf exam scores were reviewed to assess the exercise's effectiveness. Results: Surveys indicated satisfaction with the exercise and increased confidence in obtaining IC. Interestingly, the student group that received enhanced IC training had fewer shelf exam failures than those without, perhaps indicating improved fund of psychotropic medication knowledge. Discussion: Peer role-playing IC training is well accepted by students, allows practice of essential elements of IC and shared decision-making, and provides an engaging way to improve medication fund of knowledge. Our clerkship has initiated development of an IC objective structured clinical examination station and is adapting the exercise across specialties for longitudinal learning in response to the positive feedback and ease of use. Structured review of psychotropics and peer IC role-playing can be tailored for other specialties, medications, and procedures and further developed for use in pre- and postclerkship education.

Experiential Learning Cycles as an Effective Means for Teaching Psychiatric Clinical Skills via Repeated Simulation in the Psychiatry Clerkship.

OBJECTIVE: This retrospective study compares differences in clinical performance on the psychiatry clerkship Objective Structured Clinical Examination (OSCE) between students receiving traditional repeated clinical simulation with those receiving repeated clinical simulation using the Kolb Cycle. METHODS: Psychiatry clerkship OSCE scores from 321 students who completed their psychiatry clerkship in 2016 and 2017 were compared. Specific performance measures included communication skills as determined by the Essential Elements of Communication, gathering a history, documenting a history and mental status exam, defending a differential diagnosis, and proposing a treatment plan. Results were calculated using repeated two-way analysis of variance between students receiving no simulation and traditional repeated simulation training (TRS) as compared to students receiving no simulation and repeated simulation utilizing the Kolb cycle (KRS). RESULTS: Students who received KRS performed significantly better in three of the five components of the clerkship OSCE as compared to students who received TRS. Specifically, students who received KRS performed better on gathering a history (+ 14.1%, p < 0.001), documenting a history (+ 13.4%, p < 0.001), and developing a treatment plan (+ 16.7%, p < 0.001). There were no significant differences in communication skills or in developing and defending a differential diagnosis. CONCLUSIONS: Psychiatry clerkship students engaged in repeated simulations explicitly integrated with the Kolb cycle demonstrate improved clinical skills as measured by OSCE performance. Integration of the Kolb cycle in designing simulation experiences should be carefully considered and may serve as a model for individualized coaching in programs of assessment.

Pilot Study of an Online Self-Directed Learning Module for Medical Decision-Making Capacity.

OBJECTIVE: This study assessed the impact of an online, self-directed learning module on medical student knowledge and attitudes regarding decision-making capacity. METHODS: The authors created a 15-min didactic video on decision-making capacity and sorted medical students on the psychiatry clerkship to teaching as usual or teaching as usual plus watching the video. The authors assessed student knowledge about and attitudes toward decisional capacity assessment using a pre/posttest design. RESULTS: Thirty-eight students completed the study (24% of all psychiatry clerkship students in one academic year). Students who watched the video (n = 14) achieved higher scores on the posttest compared with students who did not watch the video (n = 24) (90% vs 84% on general knowledge and case examples), though this difference was small and not statistically significant. The degree of improvement from pretest to posttest was higher for students who watched the video but did not reach statistical significance. CONCLUSIONS: Overall, students found the online teaching module to be a helpful augmentation strategy for learning decisional capacity assessment. The authors incorporated student feedback and additional review to create an enhanced video, which is available on ADMSEP's Clinical Simulation Initiative website.

Inflated Clinical Evaluations: a Comparison of Faculty-Selected and Mathematically Calculated Overall Evaluations Based on Behaviorally Anchored Assessment Data.

OBJECTIVE: This retrospective study compared faculty-selected evaluation scores with those mathematically calculated from behaviorally anchored assessments. METHODS: Data from 1036 psychiatry clerkship clinical evaluations (2012-2015) was reviewed. These clinical evaluations required faculty to assess clinical performance using 14 behaviorally anchored questions followed by a faculty-selected overall evaluation. An explicit rubric was included in the overall evaluation to assist the faculty in interpreting their 14 assessment responses. Using the same rubric, mathematically calculated evaluations of the same assessment responses were generated and compared to the faculty-selected evaluations. RESULTS: Comparison of faculty-selected to mathematically calculated evaluations revealed that while the two methods were reliably correlated (Cohen's kappa = 0.314, Pearson's coefficient = 0.658, p < 0.001), there was a notable difference in the results (t = 24.5, p < 0.0001). The average faculty-selected evaluation was 1.58 (SD = 0.61) with a mode of "1" or "outstanding," while the mathematically calculated evaluation had an average of 2.10 (SD = 0.90) with a mode of "3" or "satisfactory." 51.0% of the faculty-selected evaluations matched the mathematically calculated results: 46.1% were higher and 2.9% were lower. CONCLUSIONS: Clerkship clinical evaluation forms that require faculty to make an overall evaluation generate results that are significantly higher than what would have been assigned solely using behavioral anchored assessment questions. Focusing faculty attention on assessing specific behaviors rather than overall evaluations may reduce this inflation and improve validity. Clerkships may want to consider removing overall evaluation questions from their clinical evaluation tools.

Assessment of Military Cultural Competence: A Pilot Study.

OBJECTIVE: Cultural competence is widely considered a cornerstone of patient care. Efforts to improve military cultural competency have recently gained national attention. Assessment of cultural competence is a critical component to this effort, but no assessment of military cultural competence currently exists. METHODS: An assessment of military cultural competence (AMCC) was created through broad input and consensus. Careful review of previous cultural competency assessment designs and analysis techniques was considered. The AMCC was organized into three sections: skills, attitudes, and knowledge. In addition to gathering data to determine absolute responses from groups with different exposure levels to the military (direct, indirect, and none), paired questions were utilized to assess relative competencies between military culture and culture in general. RESULTS: Piloting of the AMCC revealed significant differences between military exposure groups. Specifically, those with personal military exposure were more likely to be in absolute agreement that the military is a culture, were more likely to screen for military culture, and had increased knowledge of military culture compared to those with no military exposure. Relative differences were more informative. For example, all groups were less likely to agree that their personal culture could be at odds with military culture as compared to other cultures. Such perceptions could hinder asking difficult questions and thus undermine care. CONCLUSION: The AMCC is a model for the measurement of the skills, attitudes, and knowledge related to military cultural competence. With further validity testing, the AMCC will be helpful in the critical task of measuring outcomes in ongoing efforts to improve military cultural competence. The novel approach of assessing variance appears to reduce bias and may also be helpful in the design of other cultural competency assessments.

The Best of Both Worlds: Psychiatry Training at Combined Civilian-Military Programs.

Air Force psychiatry faces the task of training competent military psychiatrists in an era of continuing reductions. Beginning in the 1980s, the Air Force started collaborating with University partners to create hybrid training programs, civilian-military psychiatry residencies. These mergers provide stability for Air Force psychiatry training in the face of increased operational missions and uncertain military recruiting. As a result of these combined programs, Air Force psychiatry residents gain access to a broader range of civilian clinical experience and expertise while maintaining a focus on distinctive military requirements. The combining of programs opens up options for academic activities which may not have otherwise existed. Both military and civilian residents benefit from the occupational psychiatry experiences available within military clinical sites. These programs give civilian residents a chance to assist active duty members and their families and provide insight into the military "lifecycle." These collaborations benefit the universities by providing access to a larger pool of residents and faculty. The synthesis of the military and civilian programs raises some ongoing obstacles such as civilian residents' ability to gain access to military resources. The programs must also accommodate separate mechanisms for selecting residents (the National Residency Matching Program versus the Joint Selection Board for Graduate Medical Education). Military residents must also comply with military standards and requirements while maintaining the universities' standards of conduct and professionalism. Merging military training programs into university programs creates a vibrant opportunity to create exceptional military and civilian psychiatrists.

Quantifying publication scholarly activity of psychiatry residency training directors.

OBJECTIVE: The authors quantify the number of PubMed-indexed publications by psychiatry program directors during a 5-year observation period. METHODS: The authors obtained the names of general adult, child and adolescent, and geriatric psychiatry program directors from the ACGME website and entered them into a PubMed.gov database search. Then, they counted the number of indexed publications from July 2008 to June 2013 and categorized them by academic year. RESULTS: The median number of publications was one for adult psychiatry program directors (n=184), one for child and adolescent directors (n=121), and three for geriatric psychiatry directors (n=58). CONCLUSIONS: The number of PubMed-indexed publications for program directors of general adult, child and adolescent, and geriatric psychiatry residencies is relatively low. Further research is needed to identify and examine the challenges facing program directors that may limit their ability to participate in this form of scholarly activity.

Military and civilian disaster response and resilience: from gene to policy.

Disasters, such as war, terrorism, and natural disasters, affect individuals, groups, and communities. Although the focus is often on post-traumatic stress disorder (PTSD), it is only one of many potential responses to traumatic experiences. Fostering community and individual resilience can help mitigate the effects of disaster. Research, education, and early intervention are integral tools to inform an effective response. The Center for the Study of Traumatic Stress (CSTS) at the Uniformed Services University of the Health Sciences ascribes to such a model in its approach. Recent studies confirm that appreciation of biology and its relation to trauma response are necessary to our understanding of trauma's effects on humans, including trauma-associated disorders, resiliency, and recovery.

Medical students' responses to an inpatient suicide: opportunities for education and support.

OBJECTIVE: The authors review third-year medical students' questionnaires to identify the perceptions, themes, and recommendations following an inpatient suicide. METHOD: The authors reviewed the needs assessment information collected 1 year after an inpatient suicide. The information, originally gathered through responses to a voluntary e-mail questionnaire, was reviewed for general themes, types of responses, and general recommendations. RESULTS: Nearly all students were sensitive to affected colleagues. Responses suggested general appreciation of offered support. They also related themes of prevention, personal education, being personally affected, identification, sense of loss, anger, and lack of support. Those involved in the code and on the inpatient service were more likely to feel personally affected. Anger and lack of support were derived exclusively from students on the inpatient service. CONCLUSIONS: Results provide observations and preliminary suggestions regarding medical students' responses to patient suicides. Understanding these responses can assist medical student educators in responding to such events.