As an explorative study, we aimed to identify and explain elements of students’ learning experiences with video cases and how this was transferred to learning in the clinical diagnostic interview situations (32). The methodological approach in this study was inspired from an interpretivist perspective, which includes the approaches of phenomenology and hermeneutics (33). This was sought by identifying, describing, and analysing underlying interpretations of the characteristics and mechanisms of the situation from the students perspective (34). A characteristic for conducting research within the interpretative paradigm is that the researches focus on what makes sense and seek to describe the phenomena in an understandable way. This implies that there are many different approaches to data collection and analysis depending on the researches’ epistemological positions, which may generate different perspectives and themes. (35). Within the research group our backgrounds was primarily characterised by origination in clinical practice, with professions as nurse, psychiatrist, surgeon and anaesthesiologist, respectively. Our titles thus included educational anthropologist, nurse and PhD student (KP), professor and chair in clinical psychiatry (OM), clinical associate professor in medical simulation (CP) and two researches in health sciences education, associate professor (AM) and professor (CR).
Setting
The context of the study was a 4-week clinical course in psychiatry for fourth-year medical students at Aarhus University. The course included large-group preparatory lectures and subsequent clinical placements. A 2-hour lecture prepared students for the diagnostic interview with psychiatric patients. For the purposes of the study, three video-based patient cases covering the diagnostic interview with a patient exhibiting manic symptoms; a patient exhibiting psychotic symptoms; and a patient exhibiting depressive symptoms with psychotic delusions was applied to an interactive e-learning format to be facilitated in the 2-hour lecture. The patient and a doctor were both played by actors.
Video cases on diagnostic interviewing
The video cases portrayed the diagnostic interviewing communication between a patient and a psychiatrist. The diagnostic interview is regarded as unique in medicine for combining a humanistic and scientific approach to the observation and understanding of the patient’s perspectives, in regards to psychopathological symptoms which by the patient may not be visible / apparent (36). In practice, the diagnostic interview approach in clinical psychiatry is grounded in empathic descriptive phenomenology and clinical observation (37). British as well as Danish medico-legal documents specify that all doctors must be able to perform a diagnostic interview in psychiatry and interpret the findings (38,39). Although the observation and categorization psychopathology served as a basic principle in the learning material, this was somewhat subtle, and the videos did not specifically represent a step-by-step introduction to psychopathology.
The development and design of the cases was an iterative process. The content of the video cases and the design aimed to bring forth a variety of perspectives in portraying the interaction between the clinician and patient and to form the basis for discussions and reflections on how to meet the psychiatric patient. The portrayal of the patient and clinician in the video cases was inspired from multiple sources including; experiences of clinical teachers in psychiatry; medical simulation principles, existing literature on patient cases, medical students attitudes towards psychiatry, patient stories and representation of clinical psychiatry (3,14,15,40,41). Aesthetic considerations intended to meet the fundamentally ethical questions concerning respect in portraying the illness and suffering of patients (42) (43). Specialists in clinical psychiatry confirmed the authenticity of the psychopathological symptoms portrayed by the simulated patients.
The video case represented the course of a diagnostic interview as a whole, and aimed to reflect realism in time and content having a linear structure. To avoid cognitive overload and to keep focus on key learning goals, the video cases did not exceed 20 minutes (44). This format was inspired by a previous project. All video cases included 9–13 sequences paused with questions offering two choices encouraging students to reflect upon. The questions related to the observed psychopathology and patient information provided and choices of which symptoms would be most appropriate to explore. All cases started with a short referral note similar to the clinical information clinicians usually read in a patient record format before beginning a diagnostic interview in clinical practice.
A senior lecturer used the video cases during the 2-hour preparatory lectures and students were encouraged to vote (raising a coloured sheet) on the continuous built-in questions, which the lecturer used for initiating reflection and discussions among the students.
Participants
Medical students who had followed the preparatory lectures were allocated by faculty administration to their clerkship rotation at one of nine psychiatric departments located in six hospitals. We invited students by e-mail to voluntarily participate in individual interviews in the last week of their clinical rotation. Student lists including e-mail and rotation information were provided by the faculty administration. We recruited participants among the sixty-one students who attended preparatory lectures. We excluded students with clerkship placement in child, adolescent and forensic psychiatry as these departments did not let students practise diagnostic interviews. We also excluded students in clerkships far from the university due to transportation challenges. This resulted in a sample of twenty-four medical students to invite to participate in this study.
Data collection and analysis
We used the rich picture interview technique as a visual approach to understand the medical students’ experiences (45,46). Asking participants to draw their experiences in combination with interviews has demonstrated ability to unfold tacit knowledge, perceptions, and emotions of complex situations in professional practice(47).
The interviews were scheduled to last for 2 hours to enable the participant to feel comfortable to engage in a dynamic discussion (48). All interviews followed the same structure: First, the study was explained to the medical student to obtain verbal and written consent. Second, they were introduced to the visual approach (49) and instructed to draw on an A3 paper sheet in silence for 30 minutes. The written instruction was:
“Reflect upon and draw a situation from the clerkship where the preparatory video-based teaching format helped you navigate meeting and communicating with a psychiatric patient. Try to illustrate everything you perceive to be part of the situation, including ideas, people, and connections. You can also draw representations of more subjective aspects, such as figures with human characteristics, feelings, conflicts, and prejudices. ”
Finally, the interviewer used a semi-structured interview guide to expose different points of thinking departing from the key elements of the students’ rich pictures and students’ reflections related to the preparatory teaching format (32). Three researchers, CP, AM and KP, made the semi-structured interview guide to explore students’ drawings [29], [30]. The interview guide was pilot-tested with two fourth-year medical students, reviewed by two associate professors in health science education with qualitative interview experience, and refined accordingly. One interviewer KP and one co-interviewer AM were present to probe into relevant elements in drawings. All interviews were recorded and transcribed verbatim and the drawings scanned.
We conducted a thematic analysis approach inspired by Braun and Clarke to search for patterns of meaning in relation to the medical students’ experiences described in individual interviews [28], [29]. The analysis of data initially incorporated a data-driven inductive coding to explore the described diagnostic interview situation (contextual factors), and allowing the views of students’ emotional experiences and reflection of different components of the video cases to be integral to the process of the analysis (50). This was an iterative process with constant comparison and identification of codes and patterns in the dataset (51). Co-authors discussed the identification and comparison of codes and reached consensus on the themes. Finally, the data was checked for saturation.
Ethics
The Danish Research Ethics Committee exempts studies of this type from review. Students who volunteered to participate in the interviews were informed of the intention of the study and how the data would be anonymised. The students signed a written consent form with the option to withdraw from the study at any time. The collected data was stored and anonymised in accordance with the guidelines from the Danish Data Protection Agency.