Table 1 Summaries of the seven simulation cases written by participants

1 A

April 2021

Aiden, age 16, has been referred by his school social worker for behavioral concerns at school and home in the setting of his parents’ recent divorce and one parent’s gender transition. The clinician is meeting via videoconference with Aiden and his mother.

1 adolescent, 1 adult

1. To balance parent needs/expectations vs. building rapport with the patient

2. To set appropriate boundaries on inappropriate behavior from patients

3. To become familiar with research-based interventions to improve familial attunement, including approaching non-supportive caregivers with curiosity and concern rather than confrontation with corrective action and creating spaces for families to hear and realize the suffering lack of support creates across generations.

4. To explore gender roles/expectations, and cultural norms for parents and families

5. To become comfortable talking about trans health topics and providing psychoeducation to patients about gender/sex/sexuality.

2 A

June 2021

Sonya, age 15, is currently hospitalized for suicidal ideation and self-injury. The clinician is meeting with Sonya and her father via videoconference to discuss her progress and initiate medication. Sonya has not spoken to her father in six months in the setting of her parents’ divorce and strained relationship.

1 adolescent, 1 adult

1. How to reassess the clinical conclusion of a colleague and give a second opinion?

2. How to communicate alternative clinical judgment to children and families while acknowledging respect for our colleagues?

3. To identify childism, which is hidden cruelty and prejudices against children in child-rearing. As physicians, we are mostly trained to inquire about physical violence and severe neglect; but this case is about psychological abuse.

4. To inquire about adverse childhood experiences (witnessing physical violence, experiencing verbal violence, bullying, psychological abuse, and emotional neglect)

3. To assess dissociative and somatic symptoms in teenagers (paralysis, stomachache, vomiting, dizziness) due to chronic traumatization.

5. To navigate the teenagers’ attempts to autonomy (i.e., refusing to see a parent) and the legal visitation requirements. Even more when complex post-traumatic symptoms are clear but there is no physical mistreatment.

6. To inquire about teenagers’ coping strategies: addictions (weed, binge eating), self-harm.

7. Address the complaint of the parent who feels rejected by the child and the other parent.

8. Address some parents’ narcissism, lack of empathy, manipulation, and controlling attitudes.

1B

November 2021

 A continuation of case 1 A. Aiden, age 16, and his mother return to the clinic after being lost to follow-up. Aiden continues to struggle at school and home in the setting of his mother’s gender transition, along with the introduction of her partner into their home life.

1 adolescent, 2 adults

2B

January 2022

 A continuation of case 2 A. Sonya, age 15, has been discharged from the hospital and returned to living with her mother. She was supposed to begin outpatient therapy and resume contact with her father. However, she has missed all of her appointments and has not contacted her father. The clinician is meeting with her for the first time today, along with her father, via videoconference to discuss their relationship.

1 adolescent, 1 adult

3

February 2022

Hala, age 21, has been admitted to a medical floor for altered mental status in the setting of a hypoglycemic episode; she has diagnoses of type 1 diabetes, depression, and anxiety. It is day 3 of her hospitalization and she is progressing toward discharge. However, she experienced another hypoglycemic episode the previous night. The medical team consulted the CAP consult service because they are concerned about the surreptitious use of insulin for self-harm. The team searched Hala’s bag and found several insulin pens; they have not yet discussed their concerns with her. They would like the clinician to evaluate Hala for safety.

1 transitional age adult

1. To explore explicit and implicit biases while providing medical treatment to patients with mental health concerns.

2. To provide experiential opportunity in navigating a complex scenario as a consulting physician when a patient’s privacy or rights have been ignored with “good intentions”.

3. To explore the impact of countertransference on patient care.

4

March 2022

Lisa, age 15, comes to the clinic with her mother. Her mother has wanted to engage in “family therapy” but has not brought her daughter to the last five visits. Previous visits have centered on the mother’s feelings about her ex-husband and Lisa’s father. Today, her mother hopes that her daughter will confirm her suspicions of sexual abuse by her father. Her mother would like the clinician to convince Lisa to disclose the abuse or perform an exam to determine if abuse has occurred.

1 adolescent, 1 adult

1. To experientially explore the role of being a child adolescent psychiatrist when the guardian is unknowingly disrupting a therapeutic environment

2. To gain confidence in setting boundaries to a parent concerning technology and your utility as a clinician

3. To explore feelings of countertransference and how they can positively and negatively impact clinical interactions when a parent is unstable.

4. After the scenario, to discuss the dual role of being a physician and a child advocate

5

April 2022

Toby, age 15, is hospitalized for behavioral concerns at school and at home. On the unit, he has not been allowed to participate in groups because of his use of racist language toward peers and staff. The clinician is meeting with Toby and his grandmother because she is demanding that he return to participating in groups. His grandmother is his primary caregiver; her daughter passed away when Toby was very young. Toby’s grandmother is white, and Toby is mixed race; he has recently discovered that his father, who has not been present in his life, is Mexican.

1 adolescent, 1 adult

1. To explore the ability to be empathic when you don’t agree with a patient or parent’s ideology

2. To analyze your reactions in the face of racism in a patient and parent

3. Expand knowledge on how to address these situations in a therapeutic setting

6

May 2022

Brian, age 15, and his mother come to the clinic due to worsening depression symptoms, at the suggestion of a member of their church, in the setting of his father’s recent death. Brian recently joined the Nation of Islam to feel more connected to his father, who was Black. He has decided to change his name to “Divine X.” His mother, who is white and a devout Christian, is distraught about this decision.

1 adolescent, 1 adult

1. Enhance awareness of one’s limitations and strengths in addressing religious beliefs (which may or may not be maladaptive).

2. Increase comfort and confidence in navigating a patient’s religious and or racial themes during a clinical encounter.

3. Discover ways to increase one’s cultural humility.

4. Explore the conceptualization of normal syndromes of distress as distinct from depression and encompassing grief and or demoralization.

1 C

June 2022

 A continuation of cases 1 A and 1B. Aiden, age 16, and his mother return to clinic due to difficulties at home and at school. Aiden was recently admitted for suicidal ideation in the setting of breaking up with his girlfriend. His mother is concerned because Aiden has become more oppositional at home and has begun vaping. He has also been getting into fights with classmates at school.

1 adolescent, 1 adult

1. To balance parent needs/expectations vs. building rapport with the patient

2. To set appropriate boundaries on inappropriate behavior from patients

3. To become familiar with research-based interventions to improve familial attunement, including approaching non-supportive caregivers with curiosity and concern rather than confrontation with corrective action and creating spaces for families to hear and realize the suffering lack of support creates across generations.

4. To explore gender roles/expectations, and cultural norms for parents and families

5. To become comfortable talking about trans health topics and providing psychoeducation to patients about gender/sex/sexuality.