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Letters

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.

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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

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LETTERS

(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.

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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,

http://ap.psychiatryonline.org

Mass. General Hospital Boston, MA

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

Dept. of Psychiatry, George Washington Univ. Washington, DC Corr.: michael_morse@hms.harvard.edu

References

1. Wood JAV, Miller TW, Hargrove DS: Clinical supervision in rural settings: a telehealth model. Prof Psychol Res Pract 2005; 36:173–179

2. Heckner C, Giard A: A comparison of on-site and telepsy- chiatry supervision. J Am Psychiatr Nurs Assoc 2005; 11:35

3. Hilty DM, Marks SL, Urness D, et al: Clinical and educa- tional telepsychiatry applications: a review. Can J Psychiatry 2004; 49:12–23

4. Massachusetts General Hospital Division of International Psychiatry, 2009 (cited Nov. 25, 2009); available from:

http://www2.massgeneral.org/allpsych/international/

index.asp

5. Brigham and Women’s Hospital Division of Global Health Equity. 2009 (cited Nov. 25, 2009); available from: http:// www.brighamandwomens.org/socialmedicine/

6. Farmer PE, Furin JJ, Katz JT: Global health equity. Lancet 2004; 363(9423):1832

7. Quinn TC: The Johns Hopkins Center for Global Health:

Transcending Borders for World Health

8. Drain PK, Primack A, Hunt DD, et al: Global health in medical education: a call for more training and opportunities. Acad Med 2007; 82:226–230

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