DR BRIAN FITZMAURICE Department of Psychiatry Trinity College, Dublin [email protected]

VVirtual irtual IInterviews for nterviews for SStudents tudents IInteracting nteracting OnOnline (VISIOn) line (VISIOn) - novel way of learning clinical skills- novel way of learning clinical skillsFitzmaurice, B., Armstrong, K., Rogers, C., Dagger, D., Gill, M.Fitzmaurice, B., Armstrong, K., Rogers, C., Dagger, D., Gill, M.

DR BRIAN FITZMAURICEDR BRIAN FITZMAURICEDepartment of PsychiatryDepartment of Psychiatry Trinity College, DublinTrinity College, [email protected]@tcd.ie

Current VISIOn / ADAPT TeamCurrent VISIOn / ADAPT Team

Dr Brian Fitzmaurice Dr Brian Fitzmaurice Katie ArmstrongKatie Armstrong Dr Cathy Rogers Dr Cathy Rogers Prof Michael GillProf Michael GillPsychiatryPsychiatry Health InformaticsHealth Informatics Psychiatry Psychiatry PsychiatryPsychiatry

Dr Declan Dagger, & Conor Gaffney Dr Declan Dagger, & Conor Gaffney Dr Vinnie Wade, Director,Dr Vinnie Wade, Director,Programmers, Computer Sciences (KDEG)Programmers, Computer Sciences (KDEG) Centre for Learning TechnologyCentre for Learning Technology

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Global Essential Requirements in Medical EducationGlobal Essential Requirements in Medical Education(World Federation for Medical Education)(World Federation for Medical Education)

7 Core Domains7 Core Domains

Importance of Learning Clinical Interview SkillsImportance of Learning Clinical Interview Skills

History Taking contributes 60 - 80% of data for diagnosesHistory Taking contributes 60 - 80% of data for diagnoses Relative contributions of History taking physical examination, and laboratory Relative contributions of History taking physical examination, and laboratory

investigation to diagnosis in medical outpatients. Hampton JR et al, BMJ investigation to diagnosis in medical outpatients. Hampton JR et al, BMJ 1975;2:4861975;2:486

Communication skills deteriorate during medical schoolCommunication skills deteriorate during medical school Pfeiffer C, Madray H, Ardolini A, Willms J. Medical Education 1998:32:283-Pfeiffer C, Madray H, Ardolini A, Willms J. Medical Education 1998:32:283-

88

Better Communication = Fewer Malpractice CasesBetter Communication = Fewer Malpractice Cases Levinson W, Roter DL, MulloolyJP, Frankl RM. JAMA 1997;277:553-9Levinson W, Roter DL, MulloolyJP, Frankl RM. JAMA 1997;277:553-9

Poor Communications skills assoc with complaints / litigationPoor Communications skills assoc with complaints / litigationPhysician Scores on a National Clinical Skills Examination as Predictors of Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory AuthoritiesComplaints to Medical Regulatory Authorities

Tamblyn, R, Abrahamowicz, M et al Tamblyn, R, Abrahamowicz, M et al JAMA JAMA 22007;298:993-1001.007;298:993-1001.


My real concern is not whether you haveMy real concern is not whether you havefailed, but whether you are content with failed, but whether you are content with

your failure.your failure.

Abraham LincolnAbraham Lincoln


Communication training has lasting benefitCommunication training has lasting benefit Maguire, P., Fairburn S, Fletcher C. BMJ 1986;292:1573-8Maguire, P., Fairburn S, Fletcher C. BMJ 1986;292:1573-8

Simulated Patients used in majority of Medical CollegesSimulated Patients used in majority of Medical CollegesMedical School Objectives Project, Report III, (1999) Contemporary Medical School Objectives Project, Report III, (1999) Contemporary Issues in Medicine: Communication in Medicine, AAMCIssues in Medicine: Communication in Medicine, AAMC

TCD experienceTCD experience Simulated patients are expensive & logistics difficultSimulated patients are expensive & logistics difficult

Where are the problems?Where are the problems?

Typical comments from survey about learning interview skills Typical comments from survey about learning interview skills (before VISIOn I)(before VISIOn I)

““not enough opportunities for practice”not enough opportunities for practice”

““There was not a lot of opportunity to observe other doctors interviewing There was not a lot of opportunity to observe other doctors interviewing patients.” patients.”

““easy to learn from a text book but much harder when you do it in person.”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 Most useful learning method was being allowed to interview patients alone and in the video presentations”.and in the video presentations”.

Where are the problems?Where are the problems?

The SpecialistThe Specialist

one who increasingly knows more and moreone who increasingly knows more and moreabout less and less until he knows almost about less and less until he knows almost

everything about nothingeverything about nothing

Required LearningRequired Learning KnowledgeKnowledge: arrange, define, duplicate, label, list, memorize, name, order, : arrange, define, duplicate, label, list, memorize, name, order,

recognize, relate, recall, repeat, reproduce state. recognize, relate, recall, repeat, reproduce state.

ComprehensionComprehension: classify, describe, discuss, explain, express, identify, : classify, describe, discuss, explain, express, identify, indicate, locate, recognize, report, restate, review, select, translate, indicate, locate, recognize, report, restate, review, select, translate,

ApplicationApplication: apply, choose, demonstrate, dramatize, employ, illustrate, : apply, choose, demonstrate, dramatize, employ, illustrate, interpret, operate, practice, schedule, sketch, solve, use, write. interpret, operate, practice, schedule, sketch, solve, use, write.

AnalysisAnalysis: analyze, appraise, calculate, categorize, compare, contrast, : analyze, appraise, calculate, categorize, compare, contrast, criticize, differentiate, discriminate, distinguish, examine, experiment, criticize, differentiate, discriminate, distinguish, examine, experiment, question, test. question, test.

SynthesisSynthesis: arrange, assemble, collect, compose, construct, create, design, : arrange, assemble, collect, compose, construct, create, design, develop, formulate, manage, organize, plan, prepare, propose, set up, write. develop, formulate, manage, organize, plan, prepare, propose, set up, write.

EvaluationEvaluation: appraise, argue, assess, attach, choose compare, defend : appraise, argue, assess, attach, choose compare, defend estimate, judge, predict, rate, core, select, support, value, evaluate. estimate, judge, predict, rate, core, select, support, value, evaluate.

Required LearningRequired Learning

TTell me, Iell me, I’’lll forget. l forget.

Show me, IShow me, I’’lll remember. l remember.

Involve me,IInvolve me,I’’lll understandl understand..

Chinese proverbChinese proverb

Required LearningRequired Learning

VVirtual irtual IInterviews for nterviews for SStudents tudents IInteracting nteracting OnOnline (VISIOn I)line (VISIOn I)


65% used simulation more than once65% used simulation more than once

45% spent longer than 1 hour using simulation45% spent longer than 1 hour using simulation

55 % felt they were “virtually” interviewing patient55 % felt they were “virtually” interviewing patient

100% more inclined to use internet for learning100% more inclined to use internet for learning


““What was useful for learning interviews skills in Psychiatry?”. What was useful for learning interviews skills in Psychiatry?”.

Before VISIOn After VISIOnBefore VISIOn After VISIOn (n = 38) (n = 32) (n = 38) (n = 32)

1 Conducting interviews themselves 1 Conducting interviews themselves 100% 100% 100%100%2.Video interviews of themselves/others 2.Video interviews of themselves/others 80% 80% 78%78%3.Observing interviews by doctors/other professionals 78% 3.Observing interviews by doctors/other professionals 78% 74%74%4.Books 4.Books 72% 72% 74% 74% 5.Tutorials from doctors 5.Tutorials from doctors 71% 71% 70%70%6.Web based support 6.Web based support 20% 20% 76%76%

““Need more simulations to give experience across many disorders”Need more simulations to give experience across many disorders”

VVirtual irtual IInterviews for nterviews for SStudents tudents IInteracting nteracting OnOnline (VISIOn I) Studyline (VISIOn I) Study Double blind RCT of online simulator to teach Double blind RCT of online simulator to teach

communication skills to medical studentscommunication skills to medical students

VISIOn I StudyVISIOn I Study

Control group receive identical online teaching Control group receive identical online teaching package without online simulation availablepackage without online simulation available

Simulator Group Control GroupSimulator Group Control Group



Comparisons between the 2 students groups onComparisons between the 2 students groups on

A. Assessor ratings of video recorded interviews with A. Assessor ratings of video recorded interviews with patients using: patients using:

1. Leicester Assessment Protocol (LAP)1. Leicester Assessment Protocol (LAP)2. Calgary-Cambridge Observation Guide2. Calgary-Cambridge Observation Guide3. Harvard Medical School Medical Interview Scale3. Harvard Medical School Medical Interview Scale

B. Self rating of Confidence and CompetenceB. Self rating of Confidence and Competence

C. Self Assessment of Interview style/preferencesC. Self Assessment of Interview style/preferences


Data Collection nearing completionData Collection nearing completion

Analysis of early data show simulation group have:Analysis of early data show simulation group have:

A.A. Higher competence scores (LAP) in videosHigher competence scores (LAP) in videos

B.B. Lower self ratings of confidence and competenceLower self ratings of confidence and competence

C.C. More patient-centred approachMore patient-centred approach


LimitationsLimitations– Only one simulation assessedOnly one simulation assessed– Other teaching techniques confoundingOther teaching techniques confounding– Self assessment of students own skills Self assessment of students own skills

unreliable with overestimation of competence unreliable with overestimation of competence

VISIOn IIVISIOn II

Unique collaboration with the Department of Unique collaboration with the Department of Computer ScienceComputer Science

Grant funding (Enterprise Ireland Grant funding (Enterprise Ireland Technology Development Fund)Technology Development Fund)

More interviews and expansion of contentMore interviews and expansion of content Tools to enable easier creation of Tools to enable easier creation of

simulationssimulations www.simulatedinterviews.comwww.simulatedinterviews.com

http://www.simulatedinterviews.com/

Creating the dialogueCreating the dialogue

Creating the dialogueCreating the dialogue

Greeting the patient with Depression

A virtual InterviewA virtual Interview

Select a question from a categorySelect a question from a category

Our Manic Patient in full flight

Developing a rapport with our patient with Schizophrenia

Ask the experts how to interview…Ask the experts how to interview…

Mental State Examination Quiz – question examplesMental State Examination Quiz – question examples

VISIOn II EvaluationVISIOn II Evaluation

Qualitative research – questionnaires on 18 Qualitative research – questionnaires on 18 medical students and focus groupmedical students and focus group

82% accessed the tool easily by logging on82% accessed the tool easily by logging on Accessed the simulations 3 times on average, in Accessed the simulations 3 times on average, in

hospital, trinity and at homehospital, trinity and at home Average time spent on the simulator each time Average time spent on the simulator each time

was 45 minuteswas 45 minutes The average total time was 90 minutes (range The average total time was 90 minutes (range

25minutes – 4 hours)25minutes – 4 hours)


76% felt it was a valid tool for learning 76% felt it was a valid tool for learning communication skillscommunication skills

65% felt it highlighted the different learning 65% felt it highlighted the different learning objectives and skills needed for interviewsobjectives and skills needed for interviews

82% found the instructional material appropriate82% found the instructional material appropriate

88% valued the glossary as extremely useful88% valued the glossary as extremely useful


‘‘better idea of how to approach questions and areas better idea of how to approach questions and areas that are particularly sensitive’that are particularly sensitive’

‘‘made me aware of phrasing appropriate questions’made me aware of phrasing appropriate questions’

‘‘gave me a sense of the structured nature of an gave me a sense of the structured nature of an interview’interview’

‘‘also got to see the implications of different lines of also got to see the implications of different lines of questioning’questioning’


‘‘more cases of all the common disorders’more cases of all the common disorders’

‘‘include a random case with disorder not stated’include a random case with disorder not stated’

‘‘show a model interview from start to finish’show a model interview from start to finish’

‘‘loved the MSE but some kind of further assessment loved the MSE but some kind of further assessment at the end re your performance’at the end re your performance’


TTell me, Iell me, I’’lll forget. l forget.

Show me, IShow me, I’’lll remember. l remember.

Involve me,IInvolve me,I’’lll understandl understand..

Chinese proverbChinese proverb


Irish Healthcare Awards 2007Irish Healthcare Awards 2007Runner-up in “Best Use of IT” CategoryRunner-up in “Best Use of IT” Category

Online Psychiatric Teaching for Developing CountriesOnline Psychiatric Teaching for Developing Countries

Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Prof.K.A.L.A. Kuruppuarachchi MD,FRCPsych(UK), Professor of Psychiatry Faculty of Medicine, University of Kelaniya, Ragama, Sri LankaFaculty of Medicine, University of Kelaniya, Ragama, Sri LankaLetter to Psychiatric Bulletin, Oct 2007Letter to Psychiatric Bulletin, Oct 2007

Fitzmaurice et al (Psychiatric Bulletin, June 2007, 31,218-220)Fitzmaurice et al (Psychiatric Bulletin, June 2007, 31,218-220)highlight an important area in medical education, which is also relevant highlight an important area in medical education, which is also relevant to psychiatric education in many developing countries. Even though the to psychiatric education in many developing countries. Even though the morbidity due to psychiatric illnesses is very high, there is a scarcity of morbidity due to psychiatric illnesses is very high, there is a scarcity of qualified trainers in our part of the world…… qualified trainers in our part of the world……

Medical teachers in developing countries should think about Medical teachers in developing countries should think about incorporating online teaching and clinical interview skill training incorporating online teaching and clinical interview skill training programmes in psychiatry as many medical schools have access to programmes in psychiatry as many medical schools have access to online teaching facilities. It may be feasible and cost effective even in online teaching facilities. It may be feasible and cost effective even in resource poor countries.resource poor countries.

Future role of SimulationsFuture role of Simulations

Media/ Tool Cost to Develop

(Per instructional hour) [$USD]

Time Required to Develop

PowerPoint Alone $50-500 hours

Courseware $1000-35,000 months

Simulations $20,000-75,000 many months

Ongoing workOngoing work

6 Healthcare Communications Simulators can be used as: 6 Healthcare Communications Simulators can be used as:

1. Educational tool (University / Training Body)1. Educational tool (University / Training Body)

2. eLearning tool / exam preparation (student)2. eLearning tool / exam preparation (student)

Need to be evaluated outside of our University environmentNeed to be evaluated outside of our University environment- Doctors starting in Psychiatry (Spring 2007 / January 2008)Doctors starting in Psychiatry (Spring 2007 / January 2008)- Other disciplines (Nursing Students Autumn 2007)Other disciplines (Nursing Students Autumn 2007)- Other Universities (University of Edinburgh)Other Universities (University of Edinburgh)

AcknowledgementsAcknowledgementsDepartment of PsychiatryDepartment of Psychiatry : :

Prof Brian LawlorProf Brian Lawlor

Prof Michael FitzgeraldProf Michael Fitzgerald

Prof Anthony ClareProf Anthony Clare

Dr Anthony BatesDr Anthony Bates

Dr Gary DonoghueDr Gary Donoghue

Centre for Learning TechnologyCentre for Learning Technology : :

Valerie Carroll, Catherine Kane, Theresa Logan PhelanValerie Carroll, Catherine Kane, Theresa Logan Phelan

Dr Barbara Dooley, University College, Dublin (Statistical Advice)Dr Barbara Dooley, University College, Dublin (Statistical Advice)

Andrew Bates, Neil Peirce (AV work)Andrew Bates, Neil Peirce (AV work)

Maggie Armstrong (Artwork)Maggie Armstrong (Artwork)

Kate Perry, Celine Mullins, Paul Gaskor (Acting)Kate Perry, Celine Mullins, Paul Gaskor (Acting)

AcknowledgementsAcknowledgementsFunding for VISIOn from:Funding for VISIOn from:Trinity College, Dublin Trinity College, Dublin Senior Lecturer’s Office Senior Lecturer’s Office Centre for Academic Practice and Student Learning (CAPSL)Centre for Academic Practice and Student Learning (CAPSL)School of Medicine and Health SciencesSchool of Medicine and Health Sciences

Janssen-Cilag (Ireland & UK) LtdJanssen-Cilag (Ireland & UK) LtdAstra Zeneca (Ireland) LtdAstra Zeneca (Ireland) LtdEli Lilly (Ireland) LtdEli Lilly (Ireland) LtdPfizer (Ireland) LtdPfizer (Ireland) Ltd

Follow on project ADAPT:Follow on project ADAPT:Enterprise IrelandEnterprise Ireland

Further informationFurther [email protected]

Katie Armstrong,VISIOn Project Co-ordinatorKatie Armstrong,VISIOn Project Co-ordinator

[email protected] of Psychiatry, Department of Psychiatry,

Trinity Centre for Health SciencesTrinity Centre for Health SciencesSt James’s Hospital, Dublin 8, Ireland St James’s Hospital, Dublin 8, Ireland

Dr Declan Dagger, ADAPT Project ManagerDr Declan Dagger, ADAPT Project Manager

[email protected] and Data Engineering Group (KDEG)Knowledge and Data Engineering Group (KDEG)

Department of Computer Science, TCDDepartment of Computer Science, TCDTelephone:Telephone:+353 1 896 1335+353 1 896 1335

mailto:[email protected]














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DR BRIAN FITZMAURICE Department of Psychiatry Trinity College, Dublin [email protected]