1. Gary Tabas, MD University of Pittsburgh UPMC Shadyside
Provost’s ACIE Award
A Novel Approach to Teaching The Management of Diabetic Ketoacidosis Using Virtual Patient Technology
Gary Tabas, MD
University of Pittsburgh
UPMC Shadyside

2. Background Diabetic ketoacidosis (DKA) LCME ‘educational gap’
Associated with significant morbidity and mortality
Management involves complex decision making
LCME ‘educational gap’
Only a minority of students will encounter a patient with DKA during ward rotation
Liaison Committee for Medical Education, which requires that medical schools identify the types of patients that students must encounter and “remedy any identified gaps,”
Liaison Committee for Medical Education. LCME considers proposed changes in accreditation standards. December Available at:

3. Current Educational Methods
Lecture
Small group discussion
PBL (Problem-based Learning)
But management and decision making during direct patient care are often suboptimal.

4. New Educational Approach
Simulation would allow students to learn and practice DKA management skills in a safe environment
Increasing role of simulation in student training recognized by
LCME, ACGME
Carnegie Foundation report - Educating Physicians: A Call for Reform of Medical School and Residency
“Content of curriculum derived from patients seen”

5. Project Goals
Implement a newly created web-based virtual patient (VP) simulation to teach the management of DKA.
Pilot test its effectiveness in teaching
DKA-specific clinical decision making.
3. Assess students’ perceptions of the effectiveness of the DKA VP compared to other instructional methods.

6. Virtual Patient Simulation
Virtual patients are computer-based simulations of medical cases for education and assessment
Branched-Narrative VPs
Multiple pathways through the simulated case
Pathway determined by learner’s management choices
Vignette
Choice 1
Consequence 1
Consequence 2
Choice 2
Consequence

7. Learning with branched-narrative VPs
The learner acts as the practitioner who performs H&P, requests and interprets lab values and makes management decisions.
The learner sees the consequences of those decisions and adjusts management
DKA Branched-Narrative VP
Diagnose DKA
Manage fluids, electrolytes, and insulin
Transition the patient from continuous IV insulin to subcutaneous insulin

8. Methods

9. Program Development VP content sources Diabetes Care 2006; Kitabchi A.
In The Clinic; Annals Int Med 2010
Content review: Endo attending specializing in DM
Pretest/posttest:
Case-based; single best answer; NBME type aligned with teaching goals
Content review: Endo attendings and fellows
Survey: from literature; expert validation

15. Learning Management system
VpSim created by the University of Pittsburgh Laboratory for Educational Technology
Flash-based visual interface
Author creates screens and management choices using a map of nodes and branches.
Adds patient data to each node.

16. Better
volume status
saline
Hypovolemic DKA patient
D5W
oral fluids
Persistent
hypovolemia

17. Insulin & D5W
Stop insulin
Insulin & saline
Insulin & D5W

19. Track students' pathways through the case

20. Track students' pathways through the case

21. Advantages of VP Simulation
Exposure to rare patients
Incorporates adult learning theory:
Active engagement
Visualization/rehearsal (neurobiology of learning)
Adaptive learning (individualized instruction)
Self-reflection
Feedback (formative)

22. Findings To Date

23. Participants 51 Third year medical students 84 pharmacy students
AIMC
84 pharmacy students
Clinical pharmacology course
11 Endocrine fellows

24. Pretest VP (path score, time-on-task) Posttest Survey

25. Pre-Posttest Scores
*P = .026 †
† P< .001 vs all posttest

26. Selected Posttest Questions
Scores (%) † * NS
* P = † P<.001

27. VP Learning Path Score
* P< .001 vs med students

28. VP Time-On-Task
* P = .004 vs other groups

29. VP learning path score with posttest score
Correlations
Outcomes
*Correlation
P value
VP learning path score with posttest score
.31
.0002
Time-On-Task with
VP learning path score
.21
.013
* Spearman’s ρ

30. Survey Data

31. The ability to see and react to the consequences of my decisions in this module was more effective in teaching me clinical decision making than with other learning methods
All differences NS

32. The module was effective in helping me learn how to adjust therapy in patients with DKA who are not responding appropriately *
* P = .02 vs Med students

33. The module improved my confidence in managing DKA.*
* P = .01 vs other groups

34. The module was of high educational value

35. Summary
It is feasible to create a interactive branched-narrative VP to teach the management of a complex medical illness
One way to fill an educational gap
Effectiveness was significant as evidenced by pre-posttest score improvement
Students felt that the VP was effective in teaching management of DKA and preferred the VP over other teaching methods

36. Limitations Expensive, time consuming Expertise Pilot study One case
Two schools but in one institution
No patient outcomes

37. Future Research
Compare effectiveness of branched-narrative VP to traditional VP with only one learning path

38. Questions?
Funding: University of Pittsburgh Provost’s Innovations in Education Award Acknowledgements: Harsha Rao Mary Korytowski Neil Benedict Mike Elnicki Dario Torre JB McGee Laboratory for Educational Technology

40. The problem Insufficient insulin GLU HCO3 ∆ ~16 ~15 ~200
2 AM AM AM AM AM

41. What do we know about the effectiveness of web-based education?
Superior to no intervention
Probably equal to non-internet education for knowledge gain
Superior to non-internet education for learning efficiency
(knowledge gained per time spent)
Superior for learning satisfaction
Cook