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Telesupervision for Medical Student Rotations in Global Health Psychiatry

To the Editor: We report on a psychiatry rotation un- dertaken by a 4th-year student at Harvard Medical School at a community mental health center in Bethlehem, Pales- tine, in which Harvard faculty case-supervision was suc- cessfully provided through voice-over Internet technology and e-mail. One of us (MM) undertook a 4-week rotation during the fall of 2009 at the Guidance and Training Center in Bethlehem, seeing patients at the clinic for 40 hours per week. The clinic’s director, one of a total of approximately 20 psychiatrists in the West Bank and Gaza (serving a Palestinian population of more than 4 million) was available to the student as an on-site resource, over- seeing project administrator, and communicating liaison with Harvard faculty, but was unable, because of time constraints, to provide regularly scheduled clinical case- supervision to the student. The student, who was conver- sant but not fully fluent in Arabic, saw patients in con- junction with bilingual Arabic-/English-speaking clinic staff members who had completed bachelor’s or master’s degrees in social work, psychology, or related fields; pa- tient interviews took place with the clinic staff providing adjunct English translation as necessary. Approximately 75 individual patients were evaluated by the student. The student completed a written case summary of selected patients after case discussion with the clinic staff; this summary was further amended in some cases after telesu- pervision with Harvard faculty. Adult-patient cases were supervised by an adult psychiatrist (GF), and child-patient cases were supervised by a child psychiatrist (GR); both faculty members had had considerable previous experi- ence within global health, telemedicine, and telesupervi- sion. We had previously researched potential telesupervi- sion modalities, each with varying characteristics. Four easy-to-use modalities are ranked here in decreasing order of bandwidth (a measure of a communication network’s rate of data transfer) and reliability requirements:

Videoconferencing software (free through Skype, Google, and other providers) enables synchronous, real- time conversations between supervisor and trainee, includ- ing live video feeds. It requires cameras and microphones connected to computers at both sites, as well as the great- est bandwidth. It most closely approximates in-person su- pervision.

Academic Psychiatry, 35:6, November-December 2011

Voice-over Internet (free through Skype and Google) enables telephone-like conversations over the Internet and can be used simultaneously with instant-messaging. In addition, it is possible to make telephone calls to a cell phone from a computer connected to Skype, which may be an attractive alternative in settings where limited computer bandwidth precludes clear communication from computer to computer.

Instant-messaging (free through Skype and Google) allows real-time written conversation; it can be useful in settings where the trainee may be unable to secure a pri- vate space for voice-based telesupervision, although its slower pace and lack of nuance renders it less lifelike than spoken communication.

E-mail can be a useful adjunct to the above options, permitting participants to ponder complex issues in an asynchronous, written format.

Technology failure, in the form of insufficient band- width and/or poor reliability, is commonly cited as a cause of substandard telepsychiatry and telesupervision experi- ences (1–3). Our research into the Bethlehem Clinic In- ternet connection indicated that it was reasonably reliable but possessed minimal bandwidth—as is commonplace in resource-limited contexts. We therefore planned voice- over Internet telesupervision sessions occurring 1–2 times per week, each session lasting 1 hour. These sessions were augmented by individual case summaries written by the student, which were emailed to supervisors in advance of the telesupervision sessions. At the conclusion of the ro- tation, there had been a total of 5 hours of real-time voice-over Internet faculty supervision, focused on a wide range of issues (e.g., related to problems in the complete- ness of history-taking, related to the subtleties of differ- ential diagnosis, and related to the process of developing smooth cross-cultural teamwork). The medical student, the Bethlehem Clinic director, and the Harvard faculty super- visors all judged that the experience had been education- ally valuable—comparable to similar rotations in 4th-year psychiatry at mental health clinics elsewhere—in terms of the student’s increasing facility in interviewing patients and family members, completing a clinical assessment, formulating an appropriate differential diagnosis, and out- lining a realistic treatment plan. As academic medical centers are increasingly focusing on advancing health equity worldwide (4–7), institutions struggle to provide adequate global-health training oppor- tunities in the face of financial and logistical constraints



(8). Telesupervision technologies such as those listed above are available free of charge and facilitate ongoing supervision between global health psychiatry trainees lo- cated in the field and psychiatrists stationed at academic medical centers. Challenges remain on many fronts, both to psychiatric telesupervision and to telemedicine, in gen- eral. Notable issues that have not yet been fully addressed include the robust protection of confidentiality through elimination of patient identifiers and encryption of data; the standardization of best-practice clinical parameters across the variety of global contexts; and the evaluation and endorsement of telesupervision by national and inter- national medical centers and academic policy planners. We believe that psychiatric telesupervision has the poten- tial to offer considerable benefits, in view of its ease and flexibility of implementation, as well as its minimal finan- cial costs.

Michael Dorian Morse, M.D., M.P.A.


Dept. of Psychiatry, George Washington Univ. Washington, DC

Giuseppe Raviola, M.D.

Dept. of Psychiatry, Children’s Hospital Boston, MA

Gregory Fricchione, M.D.

Dept. of Psychiatry,

Mass. General Hospital Boston, MA

Elizabeth Berger, M.D., M.Phil.

Dept. of Psychiatry, George Washington Univ. Washington, DC Corr.:


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Transcending Borders for World Health

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Academic Psychiatry, 35:6, November-December 2011