Letters

Telesupervision for Medical Student Rotations in Global Health Psychiatry To the Editor: We report on a psychiatry rotation undertaken by a 4th-year student at Harvard Medical School at a community mental health center in Bethlehem, Palestine, in which Harvard faculty case-supervision was successfully 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 clinics 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, overseeing project administrator, and communicating liaison with Harvard faculty, but was unable, because of time constraints, to provide regularly scheduled clinical casesupervision to the student. The student, who was conversant but not fully uent in Arabic, saw patients in conjunction with bilingual Arabic-/English-speaking clinic staff members who had completed bachelors or masters degrees in social work, psychology, or related elds; patient 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 telesupervision 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 experience within global health, telemedicine, and telesupervision. We had previously researched potential telesupervision modalities, each with varying characteristics. Four easy-to-use modalities are ranked here in decreasing order of bandwidth (a measure of a communication networks rate of data transfer) and reliability requirements:
Videoconferencing software (free through Skype, Google, and other providers) enables synchronous, realtime conversations between supervisor and trainee, including live video feeds. It requires cameras and microphones connected to computers at both sites, as well as the greatest bandwidth. It most closely approximates in-person supervision.

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 private 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 insufcient bandwidth and/or poor reliability, is commonly cited as a cause of substandard telepsychiatry and telesupervision experiences (13). Our research into the Bethlehem Clinic Internet connection indicated that it was reasonably reliable but possessed minimal bandwidthas is commonplace in resource-limited contexts. We therefore planned voiceover Internet telesupervision sessions occurring 12 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 rotation, 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 completeness of history-taking, related to the subtleties of differential diagnosis, and related to the process of developing smooth cross-cultural teamwork). The medical student, the Bethlehem Clinic director, and the Harvard faculty supervisors all judged that the experience had been educationally valuable comparable to similar rotations in 4th-year psychiatry at mental health clinics elsewherein terms of the students increasing facility in interviewing patients and family members, completing a clinical assessment, formulating an appropriate differential diagnosis, and outlining 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 opportunities in the face of nancial and logistical constraints
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(8). Telesupervision technologies such as those listed above are available free of charge and facilitate ongoing supervision between global health psychiatry trainees located in the eld and psychiatrists stationed at academic medical centers. Challenges remain on many fronts, both to psychiatric telesupervision and to telemedicine, in general. Notable issues that have not yet been fully addressed include the robust protection of condentiality through elimination of patient identiers 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 international medical centers and academic policy planners. We believe that psychiatric telesupervision has the potential to offer considerable benets, in view of its ease and exibility of implementation, as well as its minimal nancial costs. Michael Dorian Morse, M.D., M.P.A. Dept. of Psychiatry, George Washington Univ. Washington, DC Giuseppe Raviola, M.D. Dept. of Psychiatry, Childrens Hospital Boston, MA Gregory Fricchione, M.D. Dept. of Psychiatry,

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; 36:173179 2. Heckner C, Giard A: A comparison of on-site and telepsychiatry supervision. J Am Psychiatr Nurs Assoc 2005; 11:35 3. Hilty DM, Marks SL, Urness D, et al: Clinical and educational telepsychiatry applications: a review. Can J Psychiatry 2004; 49:1223 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 Womens 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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