Co-Constructive Patient Simulation at International Conferences: Strengthening Interactions and Deepening Re�ection

Clinical training in psychiatry can pro�t from methods that can be applied in different settings and circumstances, yet use a sound, scienti�cally proven concept that enhances the learning experience. One way to create a common international community of practice (ICoP) of child and adolescent psychiatrists (CAPs) is through participation in a patient simulation session at international conferences. A co-constructive patient simulation (CCPS) was conducted as a workshop at two international CAP conferences, AACAP/CACAP 2022 and ESCAP 2023, characterized by script co-construction, active learner involvement, and systematic debrie�ng intended to enhance re�ective function in clinical practice. About 30 international learners participated each session. Two facilitators were from North America, two from Europe. The �rst session participants had to enroll in the workshop and the CCPS was played with professional actors. The second session registration was not required by the conference organization and the CCPS was played with volunteering actors with a background in psychology, unfamiliar to the public. Overarching themes included an appreciation of local and international differences in practice, legislation and clinical thinking, and shared challenges such as dealing with uncertainty, family dynamics, strong emotions, di�cult behaviour and non-adjustable perspectives. This approach can provide or expand educational resources, reveal useful common ground, (cultural) differences, and important themes in clinical practice, facilitate re�ective practice in real time, making international conferences more fun and interactive.


Introduction
Patient simulations are a great asset to clinical practice [1].Unlike role plays, they use professional actors, unknown to the public, trained to simulate patients.In Co-Constructive Patient Simulation (CCPS; [2,3]) a facilitator has additionally guided a learner to prepare a script that helps re ect on a clinical case that the learner encountered in real life and that seems t for sharing with colleagues to re ect upon.This script is then shared with actors in preparation of the patient simulation session.The patient simulation session itself has participants unfamiliar with the case, of whom two or three are invited to volunteer as interviewers of the actors being patient simulators (Ps).In this way professionals from the same or different disciplines can be brought together to re ect about clinical situations that pose ethical or societal dilemmas, clinical challenges, or practical di culties according to a particular format described earlier [3].They can exchange critiques and have a unique co-created experience and thereby develop communities of practice (CoP), that is, a group of individuals engaged in the shared pursuit of knowledge, professional a liation, and social identity.The question was whether this also could be done at international conferences with a temporary international group of colleagues, thereby creating international communities of practice (ICoP), educating twenty-rst century t child psychiatrists [4].For the CCPS set-up and debrie ng process we refer to Perlman et al. submitted [5] and Martin et al. [2,3].
In previous studies [2,3,5] shortcomings of traditional education in child and adolescent psychiatry (CAP) that can be overcome by CCPS have been described, such as: 1. Supervision takes place after clinical encounters; 2. Learning goals are driven by the instructor rather than the learner; 3. Limited ability to re ect and act in real time; 4. Lesson plans can become ossi ed.By contrast, through CCPS, 1. supervision shifts from a hierarchical to an equal encounter; 2. Learning goals become driven by the learner rather than the supervisor; 3. Re ection and action shift to happen in real time; 4. Lessons become lively and will impact the learner more meaningful through their emotional involvement.
In addition, there are clear advantages to developing collaborative spaces at international conferences, however transient: CAPs already decided to gather in a particular location for educational purposes whether, from isolated remote, rural or under-sourced areas or academic hotspots; equitable participation in a supportive, risk-free, and collegial space is facilitated.In addition to these logistic considerations, ICoPs can support common international training goals through shared development of knowledge, skills, and attitudes, or implementation of evidence-based knowledge in CAP across cultures worldwide.This helps enhance a global common understanding, language and practice of CAP bridging cultural, religious, gender and societal differences and inequality.
In this study, the rst session being also part of a larger study involving digital CCPS sessions, [5] we sought to address several of these advantages by creating and studying two ICoPs in CAP characterized by: 1) cooperation between international participants; 2) the use of human simulation, in real-time, following the co-constructive patient simulation (CCPS) model; 3) the application of the principles of design-based research (DBR) [6] and an objective evaluation framework for improvements [7].

Participants, preparation, and in-conference co-constructive patient simulation sessions
Participants were attendees at two international child and adolescent psychiatry conferences: 1) the joint American Academy of Child and Adolescent Psychiatry/Canadian Academy of Child and Adolescent Psychiatry (AACAP/CACAP) meeting in Toronto, ON, Canada (October 2022); and 2) the bi-annual meeting of the European Society of Child and Adolescent Psychiatry (ESCAP) in Copenhagen (June 2023).At the rst conference we hired professional actors with experience working as standardized patients (SPs) through the local SP program.At the second conference two psychologist (team members of one of the CCPS facilitators) also attending the conference volunteered to be SPs.We conducted both simulation and debrie ng sessions in English.Our goal for these sessions was to have CAP experience how CCPS can be used at their local clinical settings.The theoretical framework behind CCPS and how to conduct a CCPS session has been described extensively [3,5].
On the day of the simulation session, only the scriptwriter, SP, and facilitator had "inside information".All other participants had no knowledge about the case, except for a brief "door note" that set the stage for the encounter.At the rst session three participants interviewed the SP-in-role and his parent, each for 20 minutes and transitioning without interruption between one another.At the second session three participants interviewed the SP-in-role and her sister, each for 15 minutes, also transitioning without interruption between one another.They did not re-introduce themselves at the transition point: all doctors were named a generic "Dr.Jones".The point was to create continuity in dialogue and clinical reasoning regardless of the learner in the hotseat.Immediately after the session, the entire group debriefed for an hour in the rst session and 45 minutes in the second session, following best practices in healthcare.[8-10] The debrie ng session aimed to enhance participants' re ective functioning [2].

Ethics approval
The Yale University Institutional Review Board approved this study (Protocol # 2000026241).

Results
Six learners (the rst session one volunteering attendee from the USA and two of the CCPS facilitators, from the Netherlands and Canada respectively; the second session three volunteering attendees from Denmark, France, and Italy; one woman and two men each session) and about 30 international CAPs participated in the sessions each time.Two male facilitators were from North America, two female facilitators from Europe.The rst session participants had to enroll in the workshop and the CCPS was played with professional actors.The second session registration was not required by the conference organization.We conducted a 90-minute session at both international conferences.
Most participants found it challenging to sit in the "hotseat": dealing with unknown factors in the script, an unfamiliar setting, a di cult relative, and vulnerabilities of the patient with the support of peer CAPs.
Besides, participants may have been self-conscious about being in the focus of attention of the audience and its social and professional judgment.The second "Dr.Jones" tended to feel more comfortable when they had already had an example to build on from the rst "Dr.Jones".The ones in the hotseat also found it worthwhile to be able to navigate a developing interaction as well as experience the impact of their approach and interventions.They also found it rewarding to re ect on it afterwards and to get feedback from other participants in a structured and non-judgmental way.For a case example see Table 1.Especially the fact that clinical, judicial, or ethical dilemmas seldom provided the learner with clearcut answers was valuable to re ect upon.In summary, CCPS provided a setting in which learners and participants could experience actual or perceived past misses (ranging from empathic failures to medical errors); it helped learners overcome troublesome insecurities and manage their handling of all sorts uncertainties.A 16-year-old adolescent male is admitted to pediatrics for a seizure work-up that turns out to be medically non-contributory.
In meeting with the adolescent, the consulting psychiatrist has to allow the teen's voice to be heard in the face of the father's voice that dominates the interview and the illness narrative.
"I'm not asking you to ask him if it's OK for you to leave the room; I am asking you to leave the room." • Engage with an overbearing parent in the treatment of their somatically preoccupied child.
• Maintain the clinical trust and focus of an interview despite others' maladaptive or defensive efforts to derail it.

Limitations and strengths
The second session was at a conference that didn't require pre-enrollment, which apparently invited participants to come and go freely, disturbing the safe space and simulation.Also, the CCPS was played with volunteering actors with a background in psychology, unfamiliar to the public, which upfront was considered a second best to professional actors.However, this construction turned out to be no problem at all, even a learning opportunity for the volunteering psychologist actors involved.

Discussion
In this study we have described the feasibility despite logistic challenges of creating an ICoP using CCPS.We note that in-person ICoP seem to have similar strengths as virtual communities of practice [5] despite being transient.However, pre-enrollment in the CCPS session, showing up on time, staying in throughout the entire session, keeping the doors closed during the session and stating these rules at enrollment and at the start of the session seem to be practical requirements to create a safe uninterrupted, dedicated space for learning.In addition, we experience that CAP professionals, unknown to the participants at the conference, can equally serve as SPs as professional actors and at no cost.In considering the strengths, limitations, and next steps to this work, we suggest a systematic framework to evaluate ICoPs [7]. Declarations

Table 1
The experience with CCPS was novel, at a rst level, for bringing simulation into training in psychiatry, particularly CAP.It motivated learners to investigate previous "missed" opportunities in clinical practice by having them assume an active and re ective role in the process.Each of the functions in the CCPS session proved valuable (i.e., whether scriptwriter, interviewer, participant, or facilitator).