Evolving perspectives

The author discusses the Uniformed Services University of the Health Sciences (USUHS) National Capital Area Medical Simulation Center and its vision for the future of psychology's training programs

By Patrick H. DeLeon, PhD

Fascinating Training Opportunities

After having served on the U.S. Senate staff for 38+ years (i.e., the legislative branch), it is a wonderful experience to now have the opportunity to serve within a university system and specifically, the Uniformed Services University of the Health Sciences (USUHS) of the Department of Defense (DoD). Almost all of the USUHS students are active duty personnel, or have demonstrated a clear commitment for eventual federal service. Recently, one of the nursing students informed me that she had already been in the military for 17 years. To put it mildly, collectively, they are very impressive, as are the faculty. Over the years, I have been impressed by the opportunities within the public sector to develop truly creative programs, especially within the federal sector with its considerable resources and broad responsibilities. This past month I had the opportunity to visit the USUHS National Capital Area Medical Simulation Center with David Krantz, chair of the Department of Pschology. We saw first hand their vision for psychology's training programs in the 21st century.

A Report from USUHS Professor Jeanette Witter

"The use of in vivo encounters with specially trained individuals, known as standardized patients (SPs), has become an established part of medical education in the United States. SPs are professional actors, retired teachers, and laypersons trained to simulate specific challenges in outpatient, inpatient, and critical care settings. The simulated patient encounters transition students from the classroom to real patient contact in safe environments.

"The Department of Medical and Clinical Psychology at USUHS trains active duty military and civilian students to become the clinical psychologists practicing within the military and/or researchers in the field of medical/clinical psychology. Since the inception of the clinical psychology program 17 years ago, it has trained approximately 40 doctoral level clinicians who have gone on to serve the military in a range of clinical and leadership positions. One of the program's innovations has been to use SPs as a major component of the clinical training of the students, utilizing resources at the National Capital Area Simulation Center (USUHS SimCenter). This medical simulation center is a world leader in the development and application of medical simulation programs for a range of disciplines and specialties. In the clinical skills laboratory, consultation rooms are equipped with two video cameras and microphones to record the encounter. An observation area at the center of the lab allows faculty and students toobserve the encounters live or view digital recordings for subsequent analysis.

"I currently direct the clinical skills courses in conjunction with Michael Feuerstein, the director of clinical psychology training. In the first year of clinical training, students are trained to conduct comprehensive psychological assessments through academic and practical instruction. They also receive instruction in the Foundations of Psychotherapy and Cognitive Behavioral Therapy. Through the SimCenter, students simultaneously experience the practical application of the academic instruction they are receiving. In patient encounters with SPs at the SimCenter, students learn how to conduct Intake Interviews, to utilize the techniques of Motivational Interviewing, to perform formal psychological evaluations, and to give feedback to patients. They are observed in real time by teaching assistants and through videotape by their instructor, Clare Delabar, an adjunct faculty member and practicing psychologist, and they receive verbal and written feedback in supervision. The ability to review their taped encounters allows the students to observe themselves and to see and hear the specific areas highlighted in supervision.

"In the second year of clinical training, students begin their first practicum in the community and continue their academic and practical training in psychotherapy. In the past two years, we have radically revised the approach to teaching psychotherapy in order to expose the students to a wider range of theoretical approaches and techniques. Therefore in the second year of Clinical Skills Training, students take "The Art of Psychotherapy" with Leslie Cooper, another adjunct faculty member and a psychologist who works with cancer patients at Walter Reed National Military Medical Center, the hospital with which USUHS is affiliated. They are exposed to Humanistic Theory and Techniques with an emphasis on building rapport and listening to the patient's narrative. Again they are able to practice techniques taught in this class with SPs at the SimCenter and to receive immediate supervision from advanced level students who serve as teaching assistants and from their faculty advisers. Students are then instructed in Brief Dynamic Psychotherapy. In that quarter students have the experience of conducting a course of Brief Therapy (6 sessions) using the techniques of Time Limited Dynamic Psychotherapy. Finally, the students are instructed in Integrated Psychotherapy with Barry Wolfe, an adjunct faculty member with extensive experience in private practice in the community. In an innovation begun in the current academic year, the three courses are linked through patient encounters with one consistent SP. The students are introduced to the SP in Leslie's class by conducting an Intake Interview. They then conduct a six session psychotherapy course with the patient in my class, followed by two sessions in Barry's class. In total, the students see a single patient for nine visits with exposure to three therapeutic modalities. This approach to training also allows advanced graduate students the opportunity to learn to supervise beginning clinicians in conjunction with the supervising faculty member.

"The integration of hand-on-experience with didactic instruction in the risk free environment of the SimCenter allows the novice clinician to develop confidence and facility with the techniques of assessment and therapeutic intervention. It affords the clinical faculty the opportunity to assess the students directly and to adapt instruction rapidly to the needs of individual students. The realistic portrayal of the SPs, due to the skill of the actors and the training provided by the outstanding staff of the SimCenter, affords the students the opportunity to experience the challenges of clinical practice in a safe environment. That the SimCenter reflects a realistic portrait of clinical work was highlighted by one student who is assigned in the Washington VA Hospital for his first practicum. After a session in Brief Dynamic Therapy with the SP, the student, in supervision, stated: 'That's exactly the same session I had with a patient at the VA last Thursday and I didn't know what to do then either!" With the amazing technology available to the students and faculty at the SimCenter, the student was able to receive immediate feedback on a session that had direct relevance to his experience working with 'real world' patients."

As organized psychology addresses the complex professional issues surrounding telehealth and telepsychology, we would hope and expect that the profession will learn from the actual experiences of our colleagues within the federal sector, and especially those in the VA. Former U.S. Army Surgeon General (1996-2000) Ron Blanck, who is presently the Chair of the USUHS Board of Regents, noted over a decade ago that mental health/behavioral health professionals were the most frequent users of the Army's telehealth capabilities. As with the visionary SimCenter, psychologists in academia and the private sector can definitely learn from our federal colleagues. Our nation�s health care environment of the future will be patient centered, feature interdisciplinary and/or integrated care, and affirmatively utilize the incredible potential inherent in the advances occurring with communications and technology fields.

A More Personal Perspective

While transiting to a new career, I have become particularly interested in the views of respected senior colleagues who also decided to "retire." Gene Shapiro, visionary psychologist and now Professor Emeritus at Nova Southeastern University, whose U.S. Senate testimony resulted in psychology being included in the federal workers' compensation legislation: "You asked for my thoughts on retirement. Retirement for me was necessary but not what I desired. My wife, Doris, needed full time help in ambulating and the drive to work, especially during rush and evening hours, became a bit frightening. Having worked from the age of 15 to age 85, waking up without a productive goal to accomplish was difficult. My background seemed to make retirement all the more difficult. Having completed my B.S., M.S., and Ph.D. while I held various full time jobs, save a one year scholarship to Rutgers when I picked up 67 credits in the one year. What I'm trying to say is that not working was something for which I was completely unprepared. Fortunately, I had tennis to fall back on. While my game is less than it was, I've been told it is excellent for my age of 92. That keeps me occupied four mornings a week. The problem is: What to do with the rest of the hours? My home health care aide takes good care of Doris most of the time so I am reasonably free to do things, but what? I found an area of interest. Doris has been diagnosed with NPH and we have had some 'miraculous' (but limited) improvement with a very high dosage of Vitamin D. Of course, it is impossible to pinpoint the Vitamin D effect. I assembled a research team of very highly qualified neuropsychologists and developed a reasonable research design. However, everyone has his/her other  responsibilities and in spite of our good intentions the process is slow. We haven't given up and will probably present the case history at the next APA convention. My advice to everyone who asks me is: If you possibly can, never retire!"