Teaching Psychiatric Emergencies Using Simulation: an Experience During the Boot Camp

Abstract

Objective

The purpose of this study is to prepare fourth-year medical students to recognize psychiatric emergencies using simulation technology. The learning experience is accomplished during the boot camp activity designed to train fourth-year medical students in different competencies before transitioning to residency.

Methods

Ninety-eight fourth-year medical students at Paul L. Foster School of Medicine participated in the boot camp during the 2018–2019 academic year. The participation of the Department of Psychiatry was for a total of four full days divided into 3-h morning and 3-h afternoon sessions with the average of four students per hour per session. The use of high-fidelity simulation and standardized patients to recreate two different clinical scenarios representing acute psychiatric emergencies, followed by structured debriefing, was implemented. Pre- and post-qualitative surveys, which were electronically available via Qualtrics, intended to assess the effectiveness of the curriculum and course teaching modalities during the boot camp.

Results

All participants reported improvement on levels of confidence in diagnosis and management of psychiatric emergencies compared with baseline. Overall a statistically significant increase in the Likert score was noted in the post-survey analysis.

Conclusions

Teaching psychiatric emergencies utilizing high-fidelity simulation and standardized patient encounters improved student confidence in several competencies. The increase in student confidence can potentially help the learner in transitioning better to residency.

Introduction

Simulation-based medical education is an innovative tool for teaching; however, it is still underutilized mainly in the field of psychiatry. In the late 1980s, simulation was used in anesthesia and since then the use of simulation as a tool for training in education dramatically increased across universities and medical centers [1, 2]. The use of high-fidelity simulation has been rarely applied to psychiatry teaching and only recently training courses were designed specifically to expose trainees to psychiatric emergencies [3]. In a recent research, Williams et al. found that simulation improved residents’ self-confidence and knowledge when they compared the effectivity of simulation-based training for management of acute agitation patients as compared with a guide booklet in psychiatric residents [4]. Preparing medical students for residency is a subject of recent concern and evaluation from several educational entities. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) in partnership with the American Board of Medical Specialties (ABMS) initiated the Milestone Project to define progressive levels of performance for graduation competencies, with the expectation that residents achieve specific milestones before graduating from training and taking their specialty certification examination. However, as of yet there has been no agreement in the undergraduate medical education (UME) community about a common core set of behaviors that could/should be expected of all graduates. The Core Entrustable Professional Activities (EPAs) [5, 6] for Entering Residency were developed to identify a short list of integrated activities to be expected of all medical doctor graduates making the transition from medical school to residency. There are several benefits derived of EPAs such as them being activities that represent the day-to-day work, making sense to faculty, trainees, and the public, situating competencies and milestones in the clinical context in which we live and making assessment more practical. There are also some clear disadvantages. The EPAs were recently introduced in the literature and have had little operationalization worldwide. They were designed originally for the residency-to-practice transition. The EPA number 10 [6] was developed to recognize a patient requiring urgent care and diligent evaluation and management. Medical students and junior residents need to develop the ability to promptly recognize psychiatric emergencies that are life-endangering. Early recognition and intervention provide the greatest chance for optimal outcomes in patient care.

Boot camps were created to improve the students’ preparedness prior to entering residency or during the last year of undergraduate education. Following national trends, in 2018, Paul L Foster School of Medicine put forth a mandate for all fourth-year medical students to enroll in a capstone interdepartmental course that would allow students to practice their clinical skills and hone their readiness for residency. Students were tasked with diagnosing and managing acutely decompensating patients in a variety of simulated clinical environments. In an effort to improve the learner’s ability to identify common psychiatric emergencies and become familiar with critical actions needed, an interdisciplinary team of faculty and residents developed two rapid response simulation cases to be used during the boot camp. Additionally, the concept of structured debriefing was introduced providing an opportunity for one to one discussions with the learners after the simulation encounter. The purpose of this study is to enhance fourth-year medical student recognition of and intervention in psychiatric emergencies using simulation to facilitate the transition to residency.

Methods

Participants

Ninety-eight fourth-year medical students participated in the boot camp experience during the 2018–2019 academic year. The Institutional Research Review Committee for the school categorized the student survey as an exempt study. The boot camp is a curricular activity offered during the clerkship phase in which each student is required to participate during the spring of their fourth year. The primary objective of this educational activity is to ensure readiness for practice on day one of residency. This activity is offered after all the medical students have completed the clerkship rotation in psychiatry and before graduation. Learners participated in numerous activities to hone their ability to assess moderate to high complexity patients, order medications and interventions, give and receive transition of care, recognize patients requiring urgent or emergent care, and initiate appropriate management while collaborating with an interprofessional team.

During the 2018–2019 academic year boot camp, the Department of Psychiatry had a 4-day participation divided in three morning and three afternoon sessions respectively with an average of four students per hour per session. Each 1-h session included the simulation case and the structured debriefing. All medical students participated in managing two acute psychiatric emergency clinical scenarios, a middle-age confused patient and a teenage female patient with a suicidal attempt.

Educational Module

A multidisciplinary team presented two psychiatric emergency simulated cases during the boot camp. The team was composed of faculty (including authors #2, 3, and 7), residents (authors #1 and #6) and fellows of the psychiatry department who ran the cases and participated in the debriefing. The administrative and information technology personnel were responsible for the technical aspects of the simulation, including the preparation of the mannequin, standardized patient training, audiovisual effects, and recreation of the emergency room and intensive care unit settings. All patient information, including vital signs, laboratory, and imaging results were displayed on TV monitors in the simulation room. The clinical scenarios were created by Department of Psychiatry clerkship directors and faculty from the Child and Adolescent Psychiatry Fellowship Program. They included a middle-aged confused male patient (delirium tremens) and a female teenage patient attempting suicide with an intentional overdose. The topics were strategically selected based on common psychiatric clinical emergencies seen in the community. The learning objectives of this activity were delineated to achieve the EPA number 10 goals.

Simulation Setting

The cases were presented in built-in training sites that represented real hospital setting and medical equipment. Each scenario involved multiple participants such as faculty, fellows, and residents playing the role of additional helpers (receptionist, family members, bedside nurse, and consulting physicians). The simulated patient was either a standardized patient or a high-fidelity mannequin. The mannequin had a computer control that allowed interactive communication with the learner as well as manipulation of different parameters (e.g., blood pressure, heart rate, and respiratory rate) up to simulation of clinical seizures depending on learner intervention.

Two different case scenarios were prepared, one with a middle-age acutely agitated patient with a history of alcohol use disorder who developed delirium tremens and another one with a teenage patient who overdosed with opioids as a suicidal attempt.

Debriefing

After the clinical presentation and medical student evaluation and treatment plan, the cases were closed with a structured 15-min debriefing. A self-reflection about strengths and weaknesses of the performance was done. Then, a faculty or senior resident provided specific feedback based on observation and finally the main points were highlighted and additional questions were addressed.

Survey

All fourth-year medical students completed a forty-question pre- and post-boot camp survey to assess their confidence levels in various clinical skills and their goals for the 2-week boot camp. The McNemar test was used to assess differences in the responses on the pre- and post-surveys. The surveys, which were electronically available via Qualtrics, intended to assess the effectiveness of the curriculum and course teaching modalities during the boot camp. The students were assessed on various performance measures, which were linked to EPAs. Additionally, after completing all high-fidelity simulations, learners answered the “Immediate post high-fidelity simulation questionnaire.” The questionnaire was analyzed using descriptive statistics to assess the effectiveness of the simulations in achieving the educational objectives of each session. All data was de-identified and collected as part of the course curriculum.

A mixed method approach was used to evaluate the boot camp. The results of the pre- and post-surveys were linked by the course coordinator and then de-identified. The McNemar test was used to assess differences in the responses on the pre- and post-surveys. The grounded theory approach was used to identify dominant themes emerging from the 1-min papers that were then used for programmatic evaluation. The EPA-specific grading rubrics were completed for each team of students on a daily basis throughout the course. The teams were de-identified and their performance assessed for potential improvement using a test for trend analysis. As a secondary assessment, the simulation grading rubrics for each team from the first day was compared with the last day using a chi-square analysis.

Statistical Analysis

Data points were summarized as per the type of variables. Continuous data were summarized using mean and standard deviation while categorical data were summarized and compared using frequencies and percentages. Scores were compared between pre- and post-results. An ordinal logistic regression analysis was conducted to determine the likelihood of an improvement in survey results given an intervention. The ordinal logistic regression clustered the ID variable in order to compensate for any missing data between pre and post. Results were considered significant at 5%. All the statistical analyses were carried out using STATA V.15.

Result

All participating fourth-year medical students were asked pre- and post-questions about their confidence level obtaining an assessment in a patient with altered mental status, evaluating a patient with psychiatric illness, and initiating medical management of an intentional overdose. Of the ninety-eight students enrolled in the boot camp, ninety-six completed both the pre- and post-surveys. The surveys looked at the student’s perceived level of confidence. The two acute psychiatric emergency case scenarios were reflected in the following survey questions: (1) Obtaining an assessment in a patient with altered mental status (Table 1, Fig. 1a); (2) evaluating a patient with a psychiatric illness (Table 2, Fig. 1b); and (3) initiating medical management of an intentional overdose (Table 3, Fig. 1c). When comparing pre- and post-survey confidence levels, all participants reported improvement on levels of confidence in the diagnosis and management of psychiatric emergencies compared with baseline. Overall, a significant increase in the Likert score was found in the post-survey analysis as noted in Tables 1, 2, and 3 and Fig. 1a–c.

Table 1.

Obtaining an assessment in a patient with altered mental status

Likert scale	Pre (N = 98)	Post (N = 96)
	N (%)	N (%)
Not confident	9 (9.18)	1 (1.04)
Slightly confident	37 (37.76)	5 (5.21)
Moderately confident	42 (42.86)	47 (48.96)
Very confident	10 (10.2)	35 (36.46)
Extremely confident	0 (0)	8 (8.33)

Fig. 1.

a Obtaining an assessment in a patient with altered mental status. b Evaluating a patient with a psychiatric illness. c Initiating medical management of an intentional overdose

Table 2.

Evaluating a patient with a psychiatric illness

Likert scale	Pre (N = 98)	Post (N = 96)
	N (%)	N (%)
Not confident	7 (7.14)	1 (1.04)
Slightly confident	35 (35.71)	9 (9.38)
Moderately confident	38 (38.78)	37 (38.54)
Very confident	15 (15.31)	37 (38.54)
Extremely confident	3 (3.06)	12 (12.5)

Table 3.

Initiating medical management of an intentional overdose

Likert scale	Pre (N = 98)	Post (N = 96)
	N (%)	N (%)
Not confident	29 (29.59)	2 (2.08)
Slightly confident	44 (44.9)	11 (11.46)
Moderately confident	19 (19.39)	43 (44.79)
Very confident	5 (5.1)	32 (33.33)
Extremely confident	1 (1.02)	8 (8.33)

Discussion

Part of the transition from undergraduate medical education to entering residency requires the ability for learners to promptly recognize a patient requiring urgent care and offer diligent evaluation and management. Early recognition of and intervention in psychiatric emergencies provide the greatest chance for optimal outcomes in patient care. Our observational study noted that all participants reported improvement on levels of confidence in diagnosis and management of psychiatric emergencies compared with baseline. Advances in simulation technology have led to the establishment of many centers in universities and hospitals; however, the impact of this technology on training in psychiatry has had low impact [7]. There are several advantages of using simulated patients to teach psychiatry, such as increasing exposure to a range of diagnoses, risk management, and patient safety in a safe, interactive, and engaging learning activity. Additionally, simulation-based activities offer learners the opportunity to master competencies like interprofessional collaboration and team dynamics which are relevant in psychiatry, where multidisciplinary team-working has become the norm. Debriefing is an important section of the simulation and a valuable opportunity for the learners to receive constructive feedback about the assessment and intervention of the clinical presentation. During debriefing, the skills related to teamwork, communication, and professional competencies are addressed. Many challenges are faced when teaching with simulation. Many centers lack infrastructure or financial resources to use simulation regularly. Additionally, achieving sustainability warrants long-term commitment of educators. While these barriers exist, research is starting to show an improved educational experience for learners. A meta-analysis that compared the effectiveness of technology-enhanced simulation versus other instructional methods showed a small to moderate positive effect of simulation in satisfaction, knowledge, process, and product skills [8]. Regarding patient outcome, Zendejas et al. showed in another meta-analysis small to moderated patient benefits of simulation-based education in comparison with non-simulation instruction, although none of the studies included in this analysis was related to the field of psychiatry [9]. In a systematic review article by Abdool et al., there are only a few novel uses of simulation in undergraduate medical education in psychiatry, of which only one study that used a high-fidelity mannequin in the simulation training [10].

We believe this observational study adds to the current literature. Our literature review noted the paucity of studies reporting the use of high-fidelity simulation to augment undergraduate medical education regarding psychiatric emergencies. This study is one of the few that clearly highlights the benefit of utilizing simulation. Not only do the results indicate a high response rate from the participants but also a statistically significant improvement in confidence levels when encountered with a psychiatric emergency. We attribute the increase in confidence noted to several factors. The case scenarios were strategically created by board-certified psychiatrists and based on real patient encounters. The standardized patients were trained by the case authors who emphasized the importance of presenting the scenario as close to a real-life situation as possible. Debriefing was done by either faculty or senior residents and the strengths and weaknesses of the encounters were reviewed. The current study is almost unique due to the scarcity of studies that have reported using a high-fidelity mannequin to simulate psychiatric emergencies. Our study sample was homogenous; all participants were graduating fourth-year medical students who had already successfully completed their psychiatry clerkship rotation. There are several limitations to this observational single-center study. The study was only conducted at a single institution making it difficult to generalize the results. Additionally, only data from the 2018 to 2019 academic year was reviewed and analyzed. The study assessed at the perceived confidence levels of the students but it does not elaborate on how the students actually performed based on observations by educators. The study also does not follow the students into their internship or examine their performance as evaluated by program directors and clinical faculty. Besides, the study design only used before and after comparisons for the same participant, lacking a control group or comparisons with other teaching methods.

Conclusion

Traditionally, teaching psychiatric emergencies with simulation is underutilized in the undergraduate medical education curriculum. Simulation-based learning is an interactive and engaging method for medical student education that can help to improve student confidence in several competencies. This study highlights the combined use of standardized patients and high-fidelity simulation to teach psychiatric emergencies to medical students. Based on pre- and post-survey data, we found a statistically significant improvement in the confidence levels of all participants in regard to diagnosing and managing psychiatric emergencies. This increase in student confidence could assist graduating medical students in easing their transition to their graduate medical education. More research is needed to fully support the long-term benefit and theory of this educational activity.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

The study was exempt by IRB.

Informed Consent

NA