James B. McGee, MD provides insights on how the community is developing a new generation of educators skilled at using virtual patient simulation.
Imagine that you are a medical student on your first day of your first clinical rotation. After an overloaded ten hours in the pediatric intensive care unit (PICU) you return home to find three virtual patient simulations assigned to you. They have medical conditions similar to your three new patients in the ICU. With your tablet device propped up on your lap, a virtual chief resident reviews the key clinical features with you and challenges you to continue the history taking and examination and even order the initial laboratory tests. She gives you some feedback and guidance, and suggests a couple of video tutorials along with additional short practice cases.
Fast forward 10 years… As a successful pediatric intensive care physician you now possess both experience and expert clinical reasoning skills. The pediatrics professional society just sent you an invitation to three virtual patient cases that will help you meet your maintenance of certification requirements. You quickly solve the diagnostic and therapeutic challenges with apparently good patient outcomes. However, new guidelines that streamline the diagnostic evaluation were not followed and resulted in a higher cost of care. After a brief review and a few more practice cases you demonstrate competency and maintain your board certification.
Virtual Patient Simulation
The preceding examples demonstrate the range of application of virtual patient (VP) simulation-based education and assessment. Simulation in general is now a well-accepted and essential component of healthcare education, from basic skill building to clinical decision-making and assessment .1 Mannequins and part task trainers are commonly used for psychomotor and team skills and standardized patient (actors) are used to improve communication and physical exam skills. Less common but just as valuable, virtual patient simulators, ones that take place primarily on a computer screen or mobile device, are used to build cognitive skills like clinical reasoning and decision-making .2
Virtual patients take many forms and styles but tend to have in common a clinical scenario that requires the learner to interact with the on-screen patient or patients to collect clinical data like history, physical exam, laboratory and imaging studies; establish a diagnosis; and select proper therapy and manage complications over time – all based on the learning objectives determined by the educator who created the case.3 They simulate a patient encounter using physiologic models or by branching down different clinical paths based on learner input. The on-screen VP responds clinically while the student receives contextual expert feedback at the key decision points.
A Virtual Patient Screen
A prototypical virtual patient screen containing 1) textual clinical and narrative data, 2) multimedia, 3) scores and status indicators, and 4) learner decision options
The University of Pittsburgh School of Medicine, (UPSOM) has a long history of employing computer-based clinical scenarios to train medical students and physicians and more recently, pharmacists, dental students and allied healthcare students. Beginning in the 1990s the school employed programmers to develop custom software for dedicated networked student workstations. In 2010 advances in hardware, software, and cloud computing enabled UPSOM’s Laboratory for Educational Technology to create “vpSim.” This completely web-based virtual patient simulation and authoring environment is easy enough for teaching faculty to use, without the need for programmers or other technical support staff. Institutions worldwide now use this program (DecisionSim, Chadds Ford, PA) to develop and deploy hundreds of simulations for all types of healthcare providers.
Virtual patients and clinical reasoning
Research and experience with VPs suggest that this approach is ideal for teaching the essential skills of clinical decision-making and reasoning.2 This type of simulation, when properly designed, requires high-level cognitive processing skills like application, analysis, synthesis and evaluation. The learner must make decisions to progress through a case, often processing and prioritizing multiple and sometimes conflicting pieces of clinical data. Importantly, the learner receives contextual and immediate feedback as the simulated patient either improves or worsens, often supplemented by a virtual tutor’s critique.
The clinical reasoning research of both Eva and Croskerry highlights how novices and experts approach decision-making using either analytical or deductive reasoning.4, Novices tend to proceed step-by-step, with careful analysis of all possibilities,5 while obtaining a large data set of diagnostic tests. Experts, however, rely most often on inductive problem solving through pattern-recognition based on years of experience and comparison with similar cases or “illness scripts” stored in their brain. When challenged with the unfamiliar, an expert will flip back and forth between analytical and deductive reasoning. Virtual patient simulations, when carefully constructed, can provide challenges to novices and experts while adding to the learner’s library of illness scripts. They provide a structured environment to practice clinical reasoning along with personalized feedback adapted to the learner’s level and performance in the simulation.
Practical and pedagogical features of virtual patient simulation
Because VPs, once written, do not require personnel, space or physical equipment beyond an Internet-connected computer, they are the least costly means of providing practice through simulation. If needed, they can be blended with other simulation modalities like task trainers and mannequins. When serving large numbers of learners over a wide geographic area the scaling costs of VP simulation make it an attractive option for improving clinical decision-making skills. The Veterans Health Administration, the largest healthcare system in the world, is doing just that with their nation-wide virtual patient educational programs.
Simulation can mimic both common diseases that a healthcare provider should become proficient in and the uncommon conditions that a provider needs to recognize and manage expertly despite limited exposure. The breadth of conditions and decision-making scenarios possible with VPs is wider than any other type of medical simulation but obviously lacks the psychomotor and communication training capabilities that physical simulators and standardized patients possess.
Pedagogically, VP simulation tends to be more flexible than other simulation tools based on the educational design employed by the case author. An author who understands his or her students can build decision-making challenges for both novices and experts by varying the complexity of the clinical decisions and the amount of distractors and confounding elements. For example, introducing contradictory data may not be appropriate for novices but can force the expert to carefully weigh clinical decisions and obtain more sophisticated testing. Adding in features such as cost tracking and limiting the time allowed to make decisions assesses and trains even high-level experts.
Feedback provided during a virtual patient simulation can vary in style and depth. It may be scripted to the learner’s level of training or change dynamically based on his or her performance during the simulation. Learning research tells us that when feedback is immediate, personal and contextual it is more effective.4 Alternatively, VP cases can be used in a small group setting with no imbedded tutor. Students must use their own self-directed learning skills to seek answers to the patient’s clinical problems with a facilitator providing in-person guidance.
Since all activity occurs on a computer, a virtual patient system can easily track the learner’s clinical decisions and report performance metrics back to the educator, curriculum directors and the students themselves. Aggregate data can provide valuable insight into practice patterns and reveal areas for improvement.
Examples of virtual patient simulation at the University of Pittsburgh
To illustrate some of the above concepts here are a few examples of how virtual patient simulation is used at the University of Pittsburgh health sciences schools.
Supplement basic science courses with clinical cases
Supplemental and core curricular cases are a part of the medical school’s basic science curriculum and intended for self-study outside the classroom. The case is usually a stereotypical clinical scenario in order to begin to build a novices early “illness scripts” with common signs, symptoms and diagnostic evaluations. These situate the acquisition of knowledge and basic science with real patient stories to enhance learning, retention and recall.
Fill gaps in the curriculum
In order to ensure a balanced exposure to common diseases and conditions every medical school in North America is expected to track, quantify and report the type of patients encountered by its students. Janet Tworek and her colleagues outlined how virtual patients can help meet these expectations, especially when employing adaptive feedback and giving cases an authentic setting and clinical responses.6
For example, some childhood infections, such as measles, diphtheria and chickenpox, vary in incidence throughout the year. An individual student may not encounter these conditions on his or her clinical rotations so virtual patients are used to fill these gaps. Also, some institutions do not have enough of a particular specialist to train all students directly so we and others supplement live experiences with online simulations created by the local experts.
Practice before and after live clinical encounters
The deliberate practice model for developing expertise requires many exposures and repetitive practice but with variation and level-appropriate complexity. Unfortunately the clinical wards where health science students are exposed to real patients are not as controlled and predictable as the simulated world. Clerkship directors and clinical curriculum designers are now directing students to structured sets of simulated cases such as the CLIPP collection for pediatric training (MedU, Lebanon, New Hampshire) or adding their own virtual patient cases to daily rounds.
Prepare for clinical rotations and board exams
At our institution all medical students take a capstone course (Integrated Case Studies) to reinforce basic science concepts, prepare for board exams and transition to clinical bedside training. It consists of a series of cases written by local faculty and solved in groups of twelve students and a facilitator. These virtual patients connect the basic sciences to the clinical sciences and introduce students to clinical decision-making.
Board exams are, by design, are filled with clinically oriented challenges that require reasoning and higher cognitive skills to solve. Step 3 of the USMLE even includes 12 virtual patient simulations. Our use of structured VP simulations throughout the medical curriculum is intended to provide the practice necessary to develop these clinical reasoning skills.
Formative self-evaluation and practice
Neal Benedict at the School of Pharmacology uses virtual patients that he and his colleague Kristine Schonder wrote as a self-directed formative exercise to complement classroom instruction. Each case has many potential outcomes that reflect varying levels of expertise in management. Learners practice these cases over and over, trying to achieve the optimal outcome while receiving on-screen feedback and critique.7
[image 2 – ICU scenario]
Above is a screenshot from a formative evaluation case used by pharmacology students that requires them to manage a critically ill patient in the intensive care unit. Performance metrics and expert feedback is provided as the student makes complex medical decisions.
[image 3 – branching case]
The above “node map” displays a complex branching structure from a case with multiple clinical outcomes. Each endpoint at the bottom of the map represents a different clinical outcome, score and expert feedback to the learner.
Blending virtual patient simulation with other simulation experiences
Dr. Fiona Craig teaches pathology to the medical students using virtual microscopy software where students zoom and pan an on-screen pathology slide. She wrote a series of virtual patient simulations that add clinical data like symptoms, physical findings and radiographs to the virtual slide experience. Students are challenged to make clinical decisions based not only on what they can see on the slide but by synthesizing and analyzing all available information.
Continuing education of medical professionals
The latest effort in continuing education at UPSOM is lead by Dr. Gary Tabas who directs a team of faculty who write complex VP simulations to supplement a leading medical journal. These cases parallel clinical topics in the journal and go further by assessing the clinician’s ability to apply his or her new knowledge and skills to patient management challenges.
Conclusions, challenges and future directions
In this author’s analysis and observation, virtual patient simulation has become a critical component of the health science curricula at the University of Pittsburgh. It supports a wide variety of learners from first year medical students through advanced specialist training and continuing education. It is applied when developing clinical reasoning skills and exposing learners to clinical scenarios is needed.
Online access, reproducibility and the tirelessness of this technology provide practical advantages especially when the learners are geographically distributed and access learning at different times. When properly designed, a virtual patient experience can adapt to the learner based on his or her performance and self-directed needs. We blend VPs with traditional and other simulation modalities to take advantage of the teaching strengths of each technique while simultaneously building a combination of clinical skills that reflect real life encounters.
While the simulation authoring software no longer requires technicians and programmers, creating high quality teaching experiences always takes time regardless of the delivery platform. Cognitive science research tells us that exposure to numerous cases with epidemiologically accurate variation and of increasing complexity accelerates the progression from novice to expert. However, demand for expert clinicians’ time makes case writing and editing challenging. In addition, the instructional design skills and experience required to effectively use adaptive learning models, physiology models and branched clinical narratives is an emerging skill set in educators. Furthermore, cases need to be periodically updated, creating even more demand for clinical experts.
These challenges accompany any new educational tool but the effectiveness and logistic advantages of virtual patient simulation are compelling. Other than bedside teaching by an expert clinical educator, there are few other ways to teach clinical reasoning. Now that we have the means to create and widely distribute simulation-based learning it is imperative that we use them. At the University of Pittsburgh and at institutions worldwide we are developing a new generation of educators skilled at using virtual patient simulation for a cohort of learners who require and seek out effective learning experiences.
1 Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35:e1511-e1530.
2 Cook, D.A. and M.M. Triola, Virtual patients: a critical literature review and proposed next steps. Med Educ. 2009;43(4):303-11.
3 Huang, G., R. Reynolds, and C. Candler. Virtual patient simulation at US and Canadian medical schools. Acad Med.. 2007;82(5):446-51.
4 Eva KW. What every teacher needs to know about clinical reasoning. Med Educ. 2004;39:98–106.
5 Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14(Suppl 1):27–35.
6 Tworek, Janet MSc; Coderre, Sylvain MD, MSc; Wright, Bruce MD; McLaughlin, Kevin MB, PhD. Virtual patients: ED-2 band-aid or valuable asset in the learning portfolio? Acad Med. 2010;85:155-158.
7 Benedict N, Schonder K, McGee J. Promotion of self-directed learning using virtual patient cases. Am J Pharm Educ. 2013;77(7):151.
James B. McGee, MD is the Assistant Dean for Medical Education Technology at the University of Pittsburgh School of Medicine and an Associate Professor of Medicine in the Division of Gastroenterology, Hepatology and Nutrition. He directs the Laboratory for Educational Technology, which has discovered and developed a wide variety of novel e-learning applications. The most significant innovation from his lab is “vpSim,” a web-based virtual patient authoring system that is now used by throughout the world by health professional schools, professional societies, and major healthcare networks. In addition to his academic appointments, Dr. McGee is the Co-Chair of the Virtual Patient Working Group at MedBiquitous (a medical education standards developing organization) and Chair of the Scientific Advisory Board at Decision Simulation.
Dr. McGee received his undergraduate and medical degrees from Louisiana State University. He was an intern, resident, chief resident and faculty member at the University of Florida Health Science Center in Jacksonville Florida before pursuing advanced endoscopy training at Beth Israel in Boston and then joined the Harvard faculty. In 1996 he led Harvard’s Institute for Education and Research that created one of the first virtual patient applications.
He can be reached at the Laboratory for Educational Technology (+1 412-648-8993) or by email at “firstname.lastname@example.org.”
DISCLOSURE: Dr. McGee is an equity holder in Decision Simulation LLC, a commercial provider of virtual patient software.