Letters

Telesupervision for Medical Student Rotations inGlobal Health Psychiatry

To the Editor: We report on a psychiatry rotation un-dertaken by a 4th-year student at Harvard Medical Schoolat a community mental health center in Bethlehem, Pales-tine, in which Harvard faculty case-supervision was suc-cessfully provided through voice-over Internet technologyand e-mail. One of us (MM) undertook a 4-week rotationduring the fall of 2009 at the Guidance and TrainingCenter in Bethlehem, seeing patients at the clinic for 40hours per week. The clinic’s director, one of a total ofapproximately 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 liaisonwith Harvard faculty, but was unable, because of timeconstraints, 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 clinicstaff members who had completed bachelor’s or master’sdegrees in social work, psychology, or related fields; pa-tient interviews took place with the clinic staff providingadjunct English translation as necessary. Approximately75 individual patients were evaluated by the student. Thestudent completed a written case summary of selectedpatients after case discussion with the clinic staff; thissummary was further amended in some cases after telesu-pervision with Harvard faculty. Adult-patient cases weresupervised by an adult psychiatrist (GF), and child-patientcases were supervised by a child psychiatrist (GR); bothfaculty 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. Foureasy-to-use modalities are ranked here in decreasing orderof bandwidth (a measure of a communication network’srate 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 microphonesconnected to computers at both sites, as well as the great-est bandwidth. It most closely approximates in-person su-pervision.

• Voice-over Internet (free through Skype and Google)enables telephone-like conversations over the Internet andcan be used simultaneously with instant-messaging. Inaddition, it is possible to make telephone calls to a cellphone from a computer connected to Skype, which may bean attractive alternative in settings where limited computerbandwidth precludes clear communication from computerto computer.• Instant-messaging (free through Skype and Google)allows real-time written conversation; it can be useful insettings where the trainee may be unable to secure a pri-vate space for voice-based telesupervision, although itsslower pace and lack of nuance renders it less lifelike thanspoken communication.• E-mail can be a useful adjunct to the above options,permitting participants to ponder complex issues in anasynchronous, written format.

Technology failure, in the form of insufficient band-width and/or poor reliability, is commonly cited as a causeof substandard telepsychiatry and telesupervision experi-ences (1–3). Our research into the Bethlehem Clinic In-ternet connection indicated that it was reasonably reliablebut possessed minimal bandwidth—as is commonplace inresource-limited contexts. We therefore planned voice-over Internet telesupervision sessions occurring 1–2 timesper week, each session lasting 1 hour. These sessions wereaugmented by individual case summaries written by thestudent, which were emailed to supervisors in advance ofthe telesupervision sessions. At the conclusion of the ro-tation, there had been a total of 5 hours of real-timevoice-over Internet faculty supervision, focused on a widerange 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 developingsmooth cross-cultural teamwork). The medical student, theBethlehem Clinic director, and the Harvard faculty super-visors all judged that the experience had been education-ally valuable—comparable to similar rotations in 4th-yearpsychiatry at mental health clinics elsewhere—in terms ofthe student’s increasing facility in interviewing patientsand family members, completing a clinical assessment,formulating an appropriate differential diagnosis, and out-lining a realistic treatment plan.

As academic medical centers are increasingly focusingon advancing health equity worldwide (4–7), institutionsstruggle to provide adequate global-health training oppor-tunities in the face of financial and logistical constraints

415Academic Psychiatry, 35:6, November-December 2011 http://ap.psychiatryonline.org

(8). Telesupervision technologies such as those listedabove are available free of charge and facilitate ongoingsupervision between global health psychiatry trainees lo-cated in the field and psychiatrists stationed at academicmedical centers. Challenges remain on many fronts, bothto psychiatric telesupervision and to telemedicine, in gen-eral. Notable issues that have not yet been fully addressedinclude the robust protection of confidentiality throughelimination of patient identifiers and encryption of data;the standardization of best-practice clinical parametersacross the variety of global contexts; and the evaluationand 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 andflexibility 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 HospitalBoston, MA

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

Dept. of Psychiatry,George Washington Univ.

Washington, DCCorr.: michael_morse@hms.harvard.edu

References

1. Wood JAV, Miller TW, Hargrove DS: Clinical supervision inrural settings: a telehealth model. Prof Psychol Res Pract2005; 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 Psychiatry2004; 49:12–23

4. Massachusetts General Hospital Division of InternationalPsychiatry, 2009 (cited Nov. 25, 2009); available from:http://www2.massgeneral.org/allpsych/international/index.asp

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

6. Farmer PE, Furin JJ, Katz JT: Global health equity. Lancet2004; 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 inmedical education: a call for more training and opportunities.Acad Med 2007; 82:226–230

LETTERS

416 http://ap.psychiatryonline.org Academic Psychiatry, 35:6, November-December 2011