I was privileged to direct year-long Clinical Skills I & II at ‘America’s Medical School’ in the Department of Medical & Clinical Psychology. We trained both military & civilian learners in one of the most advanced medical Simulation Centers.
These courses met the ‘gold standard’ for clinical training. We used the best methods, materials, and measures to train in the most essential assessment, therapy, and supervision core competencies:
- Actors, with diverse demographics, were coached to portray patients
- Empirically validated treatment and supervision manuals
- Empirically validated measures of therapeutic relationship and skills
- Up to 14 45-minute sessions with 4 patients having multiple co-occurring conditions
- Complex therapeutic and ethical (military & civilian-related) challenges
- 360’ feedback from actors, peers, teaching assistants, & post-doc’s
- Seasoned clinical faculty supervisors (military & civilian)
- Specific self assessment ratings using minute-by-minute video review
The National Training Director invited us to the flagship Army Internship (Tripler in Hawaii) to train his faculty and other internships across the country how to adapt our methods & measures to their training.
The Council of University Directors of Clinical Psychology (CUDCP) invited us to their 2011 annual meeting, to showcase our training model – having seen our poster at the 2010 Association of Behavioral & Cognitive Therapies (ABCT) conference.
So, with 20-20 hindsight, these are my lessons learned …
Lesson Learned #1
It’s fun to work with talented actors. That said, it’s also a great deal of work to choreograph & coach each encounter. There were 4 different simulated ‘patients’ and many different actors playing them – sometimes eroding the ‘standardized’ case. Essentially, these were like soap operas and, at times, it seemed like there was a cast of thousands.
Each student met with 2 ‘patients’ for 2 years … up to 14 encounters each year per patient. It can be incredibly helpful (for therapists) to learn from that kind of ‘long term’ continuity with the same patient. Yet, the personnel costs (actors, Sim Center trainers) are probably more than most clinical programs can afford.
Lesson Learned #2
If a clinical program wanted to replicate these courses, the best features could be kept and the costly parts aren’t essential. It would be easy to simulate these patients without the Simulation Center and without the paid staff and actors. And, with free streaming communication technology available today, proprietary technology to archive videos for supervision isn’t necessary.
It might even be possible to simul-teach the course – so that many more students could be taught at once (in different locales). At least, it’s a worthwhile testable hypothesis. And, that’s what I’m suggesting in the hypothetical course ‘Resilience Skills’ in this post.
Lesson Learned #3
In our courses, students met with Seth and Candace during their first year (back-to-back sessions) and in their second year they worked with Howard and Denise. However, any individual case could be used in existing clinical courses.
Initially, Howard came in feeling pretty well. He just had some chest pain. So his primary care doc referred him for help with stopping smoking and diet and exercise management. Well, before we knew it, he had the feared heart attack. When he returned to us he was in cardiac rehab and much more ‘ready to change’ his lifestyle habits. Still, he did have quite a bit of impatience and hostility, which would flare up rather often.
But, shortly after his heart attack, Howard began having huge anxiety attacks. Not just any old anxiety. That near death incident triggered a flood of all those horrific memories from an IED attack he barely survived, before retiring from the Army last year.
And, he was always torn about how close he wanted to get … now that his ex-wife came back into the picture. We’ll let you imagine … did he get back together with her … was he able to quit smoking … did his anxiety get better?
Over 14 sessions, a crew of Howard’s were trained & coached weekly in how to portray certain challenges related to Post Traumatic Stress Disorder, Type A hostility, diet & exercise behavior change, and interpersonal conflicts. They were coached in how to give constructive written feedback to their therapist (student), about what was helpful (or not) after each session.
Denise was not only depressed, she was very angry with her doctor for dumping her on a psychologist. She had really bad physical pain. And, she believed that he just didn’t want to listen to her complaints anymore. She thought her doctor was clueless and there was no hope in sight.
Meanwhile, she was so fatigued, she had to cut back her work hours, she couldn’t make plans with people and so she was getting more isolated, she couldn’t sing in the choir anymore, she couldn’t even focus on reading. All she knew was she used to be (at least strive to be) the perfect wife and mom – maybe a little too much people pleasing. Now, they had to take care of her and she felt like a huge burden on her family. In her fifties, she felt like she was in her eighties.
In fact, she did have a lot of complaints … and wondered herself how one person could have so many things wrong with her. She had a real headache .. a real stomach ache … real pain in her joints, that seemed to move around her body … and she seemed to get sicker and sicker.
Each time her doctor prescribed a new drug, it made her feel even worse. She couldn’t stay asleep and she couldn’t remember things that were obvious to her before. Her only guilty pleasure left was smoking … she wasn’t going to give that up! Over 14 sessions, the crew of Denise’s were coached in how to portray a military wife with pain and sleep problems associated with fibromyalgia (Chronic Multisymptom Illness), depression, & low readiness to change (i.e., smoking).
Enter, angry Seth
This one was active duty in the Navy (building jets) and wasn’t coming for help – willingly. He didn’t think that his coming in late to work or fighting was such a big deal. But, his Commanding Officer threatened him. If he didn’t go to the ‘shrink’ to ‘get better’ he’d mandate that Seth seek treatment – a far more serious situation.
Even though he’d already been demoted once for getting into fights, Seth was still in denial – about a lot. It was never his fault – whatever the problem was. He knew he wasn’t like his father, the violent alcoholic. He didn’t drink like his father and he didn’t beat up on his kids. It wasn’t his fault that he didn’t feel well in the morning to get to work on time.
In his mind, he deserved to drink to forget. After all, he was the victim here. He was the one who lost his wife and 2 kids in a car accident seven years ago. He just drank to numb out the loneliness and heartache. In his mind, anybody would. What else was left for him to do?
The crew of Seth’s got doused with bourbon a few times. And, they were coached in Substance Abuse, ADHD, complicated bereavement, suicide, readiness to change … and can you tell … anger issues!
Candace was struggling with the break-up of her marriage. Her husband was acting very differently from returning from war, actually several deployments. He finally did break it off – to fall in love with a woman with children. Candace couldn’t have children. Most of her therapy was dealing with a severe depression.
Also, her primary coping mechanism was to work long hours and not take adequate care of herself. That didn’t work out too well. Twice, she ended up hospitalized – last time in a diabetic coma. It’s complicated. Candace had diabetes from a very young age. Her mother literally hovered over her day and night, checking her blood sugar.
So, Candace unfortunately learned to become too dependent on her mother – and then her husband – for basic self-care. Consequently, as an adult, she struggles with ambivalence about self-care of her diet, exercise, and diabetes self-management skills – but has no idea why.
Candace’s were prepped in how to portray a Major Depression, dependency issues, and medically non-compliant behavior related to Diabetes self-care.
My Wish: Reduce Over-Prescribing via ‘ONE’ Training/OSCE
Academic Health Centers use OSCE’s to assess simulated clinical competencies. Imagine schools sharing ONE Training & OSCE that targets improvement of actual practice. ‘ONE’ refers to Open Networked Education shared by schools – to compete to have the most impact. Hypothesis: Can ONE Insomnia OSCE + QI reduce over-prescribing?
The Chronic Care Model suggests the top job of clinicians is to skillfully ‘inform & activate’ patients to use proven practices. Too few do. This clinical skill deficit results in population-level failures (e.g., over-prescribing sleeping pills for insomnia).
An initiative of 22 primary care practice-based researchers (PBRNs) found that quick referrals to informative websites improved the delivery and effectiveness of health behavior change services in primary care practice. Imagine if future clinicians practiced learning the ONE Hub handoff’ to convey ‘what works’ and where to find it – locally or online.
Learners could take the ONE Social Practicum (anywhere, anytime) using the Insomnia Hub (and other subsequent Health Hubs such as for Chronic Pain, Smoking Cessation, etc.). Clinical programs could share ONE Insomnia OSCE challenge to evaluate skills in performing a quick digital handoff.
Educators (anywhere) could measure and improve (QI) how much they reduce over-prescribing of sleeping pills – at both the clinical and population levels – in their respective health centers. Perhaps IHI Open School Chapters could compete to have the most impact. Anyone game?
Special acknowledgement goes to the many years of dedicated teams of Faculty, Fellows, & TA’s who made directing Clinical Skills richly rewarding. The 2010 crew is pictured below, beginning with Associate Professor Holloway.