Virtual Patients and Virtual Worlds

COMPUTER-BASED PROBLEM SOLVING EXERCISES A series of physiological models are available for cardiovascular physiology ("McMan"), respirology ("McPuff"), renal physiology ("McPee), and pharmacology ("McDope"). The student is presented with basic clinical data about his "patient" and may ask for further clinical or investigative information. He then proceeds to administer various forms of treatment and receives feedback about the physiological and clinical effects of his manipulations.

So, if that isn’t the way that VPs developed (in 2005)… Why didn’t they develop that way? Why did we need them? and- What did we get from them?

why did we need them... ● Short stays in hospital ● Increasing specialisation ● Increasing pressure on clinical time ● Reduced teaching time ● Trend towards standardisation in competency training

To create a shared online bank of 320 VPs, adapted for multicultural, multilingual use: for the improved quality and efficiency of healthcare education across the EU EC-funded grant (1.8 million euros) electronic Virtual Patients eViP

What DID we get from them? ●Provided greater exposure to different scenarios ●Practise of ‘correct’ clinical decisions ●Provided safe practice – and feedback ●Allowed rehearsal ●Provided a good self-directed learning tool ●Provided a trigger for basic and clinical science learning

What is a virtual patient (VP)? “An interactive computer simulation of real-life clinical scenarios for the purpose of medical training, education, or assessment”

September

What are (electronic) VPs best for? ● Students will always like VPs- –Excellent for remote/mobile access, –learning when, where you like –Attractive, image rich –And above all, core subjects for their profession ● But given the choice, - they prefer a book! ● So what can we do, - that can’t be done - with a book?

So..how do we find uses for VPs that are NOT just ‘page-turners’? They should do things that paper cannot do?! - Assessment Virtual Patients - Decision-making Virtual Patients (?) - ‘True’ Virtual Patients?

Assessment – example 1

- Blueprinting - According to Key-Feature-approach (Page und Bordage 1995) - Review - Realisation using CAMPUS-software -> Question type: Long Menu -> Long menu lists are based on the CAMPUS vocabularies Universitätsklinik für Kinder- und Jugendmedizin Heidelberg Development of VPs for assessment (Key-Feature-approach)

Universitätsklinik für Kinder- und Jugendmedizin Heidelberg Example of a VP for assessment Introduction: Six week old male infant with projectile vomiting 1. What is your initial diagnosis? -> Hypertrophic Pylorusstenosis 2. Which initial laboratory tests besides electrolytes, glucose and full blood count would you order? -> Blood gas analysis 3. By means of which technical examination do you verify your initial diagnosis? -> Sonography abdomen

M. Fischer18 Online-exam study using Key-feature-VPs Key-Feature-approach (Bordage & Page 1995) for assessment of clinical decision making of undergraduate students: „Solution“ of the problem of content-related knowledge VPs focused on main clinical decision nodes and common errors Automatic analysis of results Long menu answer format (Schuwirth 1996) Fischer & Kopp 2004

What are VPs best for? From David A Cooke, AMEE Genoa 2006, and Medical Education 2009, 43

What can VPs provide for decision-making? ● What effective learning requires, ideally, is: ● Doing ● Failing! ● Reasoning…generating explanations for failure, then ● Trying again! ● Well-told stories ● Just-in-time instruction ● And then: the VP would be doing for medical students – what flight simulators do for trainee pilots

The simple decision-making virtual patient… ●Scenario.. ●Choices and consequences ●Feedback to the student, (based upon the consequences) Suitable players: OpenLabyrinth, vpSim

… A type of Virtual Patient Problem-Based Learning

Interactive VP-based Learning!

VP/PBL TRIAL Groups Type of VP Case 1Case 2Case 3Case 4Case 5 1-5LinearBranchedLinearBranched 6-10BranchedLinearBranchedLinearBranched Year 2 students whole module trial

Student FEEDBACK ‘Decision-Making’ ‘The biggest benefit I believe is the decision making.’ ;We tried hard and we still killed the patient! I will never, ever, forget that!’ ‘Its not the decisions, it’s the consequences!’ ‘More than once we deliberately went down the 'wrong' track to see what happened. Very useful to do this on a virtual patient …’ ‘Paper’ ‘Not having a paper copy of the tutorial makes everyone in the group look at the screen rather than at each other.. ‘ ‘I think probably, as a year, we are just used to having paper!’ ‘I was dreading this as I am used to scribbling all over the notes as we talk…Actually I found this OK.’

Why do we need VPs? (1 of 2) ●Provide students with an opportunity to develop and practice their clinical reasoning and decision making skills ●Provide students with an opportunity to learn by making mistakes I just killed the patient! (“..the poorer the choice the student takes, the richer the learning experience”..)

A new programme To change the existing PBL curriculum, to create a more interactive, personalised model of course delivery with virtual patients at its core To be delivered in the Transitional year between campus-based learning and clinical attachments, as Clinical PBL Outcome-

G1 – Subject- or discipline-based G2 - System-based G3 - Case based, but linear G4 – Interactive with options, consequences Why G(eneration) 4?

So, where next? ●“…options are all very well- but I would like to see infinite options, not a few preset choices!” M.Fischer, eViP project meeting, Munich 2008 ●I would like to do a PhD in simulation, but I would also like to do a PhD in VPs! Is there any way that VPs can run simulations….? Eleni Dalfi mEducator kick –off meeting, Thessaloniki, May 2009 ●“Why are virtual patients not Virtual Patients –you know, people you can ‘see’, who move around.. in your computer….” (!) Daffyd Walters, Head of Paediatrics, St George’s ●‘Its good – greater realism would be even better!’ St George’s student

Virtual Patients in Virtual Worlds

Conclusion? Will virtual patients come full circle and return to the ambitious aims of the algorithmic VPs – physiological simulations - of the 60’s? (i.e. can Eleni Dalfi REALLY do a PHD combining VPs and simulations??) Will VPs really become as useful as flight simulators?

Thank you On behalf of the whole e-Learning Unit, St George’s University of London and Rachel Ellaway (our visiting Prof!) and the eVIP team!