Introduction

Worldwide, medical education went through significant changes due to concerns for the safety of patients. Medical errors result in as many as 98000 deaths per year in the United States of America. Changes in instructional methods have resulted in ingenious medical curricula, and one of the changes was the universally accepted proficiency in clinical skills, which constitute an essential learning outcome. The challenge for medical undergraduates is the application of theoretical knowledge to the management of patients. Simulation-based learning becomes a necessary tool as a new teaching method for undergraduate and postgraduate education.[1][2] Simulation of real-life experiences develops skills for better communication between members, rapid thinking, able to cope with new crises medical situations to make medical decisions on the spur of the moment.[3] Simulation can take part in many settings, including a medical floor, classroom, or even online.[4] Required specific skills and attitudes are part of the training in psychiatry. These skills and approaches must be experienced and not merely memorized. Medical simulation in psychiatry via appropriate training may be particularly adaptable to this situation.[5]

Function

Simulation starting back in the early 1900s. It has been used in dentistry, nursing, and medicine. Thus the field is not new to healthcare professionals. A medical simulation uses virtual reality, mannequin, and task trainers, for example, and even standardized patients to mimic a real patient or a real environment. Medical stimulation's goal is to be able to teach healthcare professionals about therapeutic and diagnosis processes, medical concepts, and decision-making steps.[6][5] The process of simulation is somewhat artificial; however, the concept is of ongoing practice and development of clinical skills. Importantly, simulation is an alternative to real patients.[2]

In the field of psychiatry, new conditions that require urgent clinical attention are behavioral and are different from other simulations in general medicine or surgery. Medical simulation in psychiatry is a relatively new field and continues to have ongoing development and changes. Simulation has both used in the psychiatric community setting as well as new mental conditions.[7]

Issues of Concern

Simulation in psychiatry is not limited merely to the use of mannequins or even video training. Simulation in psychiatry also needs in vivo and human simulation to make the experience as realistic as possible. Simulated patients can produce the same as they provide in an environment where the learner can explore and understand the occurring psychiatric situation[8]. There are opportunities for role play in psychiatry or the experience of learners attempting to simulate a real-life situation[9]. Medical education in psychiatry has become more innovative, and different education systems in different countries have developed their curriculum around it.

Curriculum Development

The principal use for simulation is to improve formative training in psychiatry. Simulation as technical competence may be an opportunity to learn deliberated practice.[10]

A. Behavioral emergency

 The most common scenarios include the use of emergency behavioral codes, including members of mental health teams, role-playing patients in behavioral health crises. Students often receive training about behavioral health emergencies, which typically involve a patient in crisis, which may include a team member posing in an agitated manner, e.g., screaming and pacing and often behaving in physically aggressive behavior. Learners are expected to be able to learn to de-escalate a patient in crisis using verbal techniques. Besides, learners need to learn about the use of physical and chemical restraints and to understand when to use appropriate methods of restraint.[11] Notably, as several professionals in mental health, learners learn to be able to respond to debriefing techniques. Training facilitators in debriefing techniques is critical to ensure effective debriefing among simulation faculty.[12]

B. Medical emergency in psychiatry

B.1.Neuroleptic malignant syndrome (NMS).

Neuroleptic malignant syndrome (NMS), first recognized in the 1960s, is a rare and potentially life-threatening adverse drug reaction (ADR).[13] The characteristic symptoms of NMS include hyperthermia, "lead-pipe" muscle rigidity, altered mental status (AMS), and autonomic instability.[14].One way, learners work with these patients is to have simulated patients in an appropriate emergency room setting. Often an external actor is brought on to role-play the part of a patient undergoing the symptoms. Another actor will role-play the role of a nurse. Medical equipment can help to simulate autonomic instability as well, and learners can work on understanding and diagnosing an emergent medical condition in psychiatry.

B.2.Serotonin syndrome

Another typical medical emergency seen in psychiatry is a drastic elevation of serotonin levels in both central and peripheral nervous. The syndrome presents a triad of autonomic dysfunction, neuromuscular excitation, and altered mental status.[15] Serotonin toxicity starts within hours of ingesting drug(s) that cause an increase in serotonin. Similarly, like neuroleptic malignant syndrome above, features of serotonin syndrome can be reproduced in a simulated setting via using an actor as a patient and then having another actor role-play the nurse. Learners again are taught to understand and diagnose this potential life-threatening emergency associated with the use of serotonergic agents.

C. Simulation training for communication skills in psychiatry

Residents or medical students may learn situational awareness, teamwork, and be able to call for help early.[16] They are crucial abilities to be able to manage psychiatric emergencies safely. For example, debriefing covers interpersonal interactions with other staff and reflect on the development of a therapeutic alliance.[11] Simulation training can reproduce realistic learning environments to facilitate the teaching of communication skills in mental health. 

D. Video assessments 

Video assessments use virtual patients and are often the de facto mode of teaching and learning. This mode of education can be accessible among many institutions around the world. A recent study has shown that more non-traditional teaching was at a disadvantage as even graphic display or poor skills more easily translate on camera.[17] There are situations where even modes of telepsychiatry are useful, and simulated patients can present for the same.[18].There is limited use of standardized patients for therapy training, including individual and family therapy. Most of the data collected on the use of standardized patients are again limited to a specific outcome or even giving feedback to learners. Some of the concerns raised were the potential of the actor's transference in a simulated situation and the lack of spontaneity in the future clinical realm.[19]

Procedural Skills Assessment

Assessment of medical students is measurable via the use of the Kirkpatrick model. The Kirkpatrick model has four levels of assessment which are:

• Level 1 = participants react favorably to the learning or intervention.
• Level 2 = participants acquired knowledge, skills, and attitudes based on the intervention or study.
• Level 3 = participants applied what they learned into practice.
• Level 4 = once applied, there was an outcome to that application of skills learned from the intervention.

One advantage is that one can continue to evaluate the application of skills learned in a simulated setting to real-life situations. This method derives from the book-Kirkpatrick DL, Kirkpatrick JD. Implementing the four levels: a practical guide for effective evaluation of training programs. California: Berrett-Koehler;2007.

A discussion of the practical application of the method appears in some of the review papers.[20]

Medical Decision Making and Leadership Development

Well-designed simulation environments create almost in vivo training environments and can go a long way in teaching teamwork, team building, and communication. Studies have also have shown that this can help students empathize more with their patients.[16]

A review of literature from several databases including MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, ERIC, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Web of Science (Science and Social Sciences Citation Index), concluded that there is a lack of literature to substantiate the benefit of simulation on mental health patient outcomes. However, findings suggest that the use of standardized patients is more common in education. Standardized patients appear to be as useful to assist in mental health education.[20] Several studies showed that communication skill enhancement and overall were positive in the use of simulation for education.[11][21][22] Similarly, virtual training via a computer was notable for skill enhancement among trainees in medical systems. There has been some research done for non-physician learners as well. A study showed that communication skills improved in nursing students with exposure to medical simulation.[23] 

In terms of medical decision making, there are several advantages of using simulated patients to teach psychiatry. For one- many keys and crucial diagnoses may be enacted, be it patients with an acute mood disorder or psychosis.[24] From here, students may be able even to assess symptoms and formulate for risk assessments.[25] This a crucial part of psychiatry and requires almost years of practice to develop. As described in some cases above, there may also be a simulation of the physical examination aspect. Again communication skills and overall comfort with persons with psychiatric illness can only improve.[26]

Some of the disadvantages include certainly the expense and the set up the curriculum for psychiatric education. Currently, there is no data on expenses on simulated patients in the United States of America; however, there is some data in the United Kingdom. Of course, there is no standardization of simulated patients; hence, the quality of education may vary from institution to institution. Also, there is the question of then reproducing the skills in real-life situations, all of which are not amenable to simulation.[27]

The use of simulation is overwhelmingly positive for the development of leadership skills since it has shown to increase communication and teamwork. Most learners came away with higher levels of confidence, which adds to be better future leaders. 

Continuing Education

In terms of continuing education, simulated patients can test for placements in levels of psychiatry- even in post-graduate psychiatric training or residency.[28] Of note, video simulation has become increasingly popular in the psychiatry board exams (conducted by the American Board of Neurology and Psychiatry), where videos get presented in the form of case simulations, and often questions follow this initiative. Video simulation has become more popular as a mode of testing as now video vignettes are about 40 to 50% of the tests.

There are innovative methods to evaluate clinicians via simulated patients and the use of video simulation. A group of researchers in Massachusetts were able to successfully test out about 400 participants for ongoing clinical evaluations and based on testing. They were able to use the testing to identify physicians and non-physicians for further training for better clinical assessments as needed.[29]

Clinical Significance

Simulated patients have several advantages for learning. Simulation can improve communication skills, leadership, and teamwork, which overall gives a learner more confidence and ability to navigate real-life clinical situations. Clinically this may translate to better clinical care. More research and studies are necessary to understand whether students that worked with simulated patients do better clinically as compared to their counterparts.

Pearls and Other Issues

Simulated patients play a more significant role in the world of medicine. Psychiatry, as compared to the full world of medicine and surgery, remains somewhat behind, but various articles, especially from the world of education, continue to show the advantages of simulation in psychiatry. Benefits include in vivo practice, more exposure to psychopathology, better communication, and learning teamwork.

Some limitations continue to be the lack of standardization for actors portraying simulation, lack of specific guidelines on simulation, and unclear costs. However, simulation and the use of technology continue to remain the future and must be incorporated in education as well. More research is needed to assess for long term clinical advantages with persons who have had training with tools of medical simulation.

Enhancing Healthcare Team Outcomes

Medical simulation in psychiatry can enhance healthcare team outcomes through:

• Acquisition of appropriate skills to perform a mental status examination
• A better understanding of psychopathology through role-playing
• Enhance residents or students' confidence in conducting a thorough psychiatric evaluation
• Be a standardized tool to assess resident or student clinical skills performance
• Improve patient safety
• Facilitate immersive learning in acute psychosis, mania, etc. (by stimulating realistic scenarios)
• Promote experimental learning