Uno Fors

Development, implementation and pilot evaluation of a Web-based Virtual Patient Case Simulation environment – Web-SP

BackgroundThe Web-based Simulation of Patients (Web-SP) project was initiated in order to facilitate the use of realistic and interactive virtual patients (VP) in medicine and healthcare education. Web-SP focuses on moving beyond the technology savvy teachers, when integrating simulation-based education into health sciences curricula, by making the creation and use of virtual patients easier. The project strives to provide a common generic platform for design/creation, management, evaluation and sharing of web-based virtual patients. The aim of this study was to evaluate if it was possible to develop a web-based virtual patient case simulation environment where the entire case authoring process might be handled by teachers and which would be flexible enough to be used in different healthcare disciplines.ResultsThe Web-SP system was constructed to support easy authoring, management and presentation of virtual patient cases. The case authoring environment was found to facilitate for teachers to create full-fledged patient cases without the assistance of computer specialists. Web-SP was successfully implemented at several universities by taking into account key factors such as cost, access, security, scalability and flexibility. Pilot evaluations in medical, dentistry and pharmacy courses shows that students regarded Web-SP as easy to use, engaging and to be of educational value. Cases adapted for all three disciplines were judged to be of significant educational value by the course leaders.ConclusionThe Web-SP system seems to fulfil the aim of providing a common generic platform for creation, management and evaluation of web-based virtual patient cases. The responses regarding the authoring environment indicated that the system might be user-friendly enough to appeal to a majority of the academic staff. In terms of implementation strengths, Web-SP seems to fulfil most needs from course directors and teachers from various educational institutions and disciplines. The system is currently in use or under implementation in several healthcare disciplines at more than ten universities worldwide. Future aims include structuring the exchange of cases between teachers and academic institutions by building a VP library function. We intend to follow up the positive results presented in this paper with other studies looking at the learning outcomes, critical thinking and patient management. Studying the potential of Web-SP as an assessment tool will also be performed.More information about Web-SP: http://websp.lime.ki.se

Building a virtual patient commons.

Virtual patients as a form of educational intervention can take many forms and can provide highly effective ways of addressing reduced student access to real patients, the need for standardised and well-structured educational patient encounters, and opportunities for students to practice in safe and responsive environments. However, virtual patients can also be complicated and costly to develop. As a result collaborative and distributed development is best suited to their widespread take up. This paper considers the development and use of virtual patients and the steps that have been taken to support authors in making this approach more sustainable and adaptable. In particular, this has involved the development of a common data interoperability standard, which in turn has engaged a number of communities that have developed, or are developing, virtual patient commons, consisting of shared resources, tools and knowledge for mutual benefit. The paper illustrates how innovative and otherwise difficult to sustain models for supporting and extending healthcare education, such as virtual patients, can be supported using a commons approach with commonly agreed data standards and specifications at their core.

Interactive simulated patient: an advanced tool for student-activated learning in medicine and healthcare

An advanced learning system for interactive simulation of patient cases (ISP) is described. The system was designed to meet specific pedagogical needs where student activation and problem orientation were two of the key issues. The system includes features such as video based illness history-taking function using free text input, highly interactive physiological examination procedures, extensive laboratory tests and detailed user feedback. The system was constructed mainly in Authorware Professional, starting more than 10 years ago, and it is now available in refined versions in different languages. Twelve pedagogical and three technical features were initially defined for the project. All of these aims were fulfilled. The ISP system has been successfully used in education, and in international collaboration, including three applicability field tests. The system is also a powerful research tool for studying for instance medical decision-making.

The use of virtual patients to assess the clinical skills and reasoning of medical students: initial insights on student acceptance

Background: Web-based clinical cases (“virtual patients”, VPs) provide the potential for valid, cost-effective teaching and assessment of clinical skills, especially clinical reasoning skills, of medical students. However, medical students must embrace this teaching and assessment modality for it to be adopted widely. Method: We examined student acceptance of a web-based VP system, Web-SP, developed for teaching and assessment purposes, in a group of 15 second-year and 12 fourth-year medical students. Results: Student acceptance of this web-based method was high, with greater acceptance in pre-clinical (second-year) compared with clinical (fourth-year) medical students. Students rated VPs as realistic and appropriately challenging; they particularly liked the ability of VPs to show physical abnormalities (such as abnormal heart and lung sounds, skin lesions, and neurological findings), a feature that is absent in standardized patients. Conclusions: These results document high acceptance of web-based instruction and assessment by medical students. VPs of the complexity used in this study appear to be particularly well suited for learning and assessment purposes in early medical students who have not yet had significant clinical contact.

Computer-aided DSM-IV-diagnostics – acceptance, use and perceived usefulness in relation to users' learning styles

BackgroundCDSS (computerized decision support system) for medical diagnostics have been studied for long. This study was undertaken to investigate how different preferences of Learning Styles (LS) of psychiatrists might affect acceptance, use and perceived usefulness of a CDSS for diagnostics in psychiatry.Methods49 psychiatrists (specialists and non-specialists) from 3 different clinics volunteered to participate in this study and to use the CDSS to diagnose a paper-based case (based on a real patient). LS, attitudes to CDSS and complementary data were obtained via questionnaires and interviews. To facilitate the study, a special version of the CDSS was created, which automatically could log interaction details.ResultsThe LS preferences (according to Kolb) of the 49 physicians turned out as follows: 37% were Assimilating, 31% Converging, 27% Accommodating and 6% Diverging.The CDSS under study seemed to favor psychiatrists with abstract conceptualization information perceiving mode (Assimilating and Converging learning styles).A correlation between learning styles preferences and computer skill was found. Positive attitude to computer-aided diagnostics and learning styles preferences was also found to correlate.Using the CDSS, the specialists produced only 1 correct diagnosis and the non-specialists 2 correct diagnoses (median values) as compared to the three predetermined correct diagnoses of the actual case. Only 10% had all three diagnoses correct, 41 % two correct, 47 % one correct and 2 % had no correct diagnose at all.ConclusionOur results indicate that the use of CDSS does not guarantee correct diagnosis and that LS might influence the results. Future research should focus on the possibility to create systems open to individuals with different LS preferences and possibility to create CDSS adapted to the level of expertise of the user.

Virtual patient simulation for learning and assessment: Superior results in comparison with regular course exams

Background: Our study aimed to observe the differences in assessment results between virtual patient simulation (VPS) and regular course exams in an Internal Medicine course for undergraduate medical students. Methods: Four cohorts of students (n = 216) used: a VPS or lectures for learning (terms 1 and 2); VPS and lectures or only lectures (term 3); and a paired set-up with both VPS and lectures (term 4). The assessment results, measured with both a VPS-based exam and a paper-based exam, were compared. A scoring rubric (0–6), developed and validated for the purpose of the trial, was applied to both types of assessment. Mean score differences of the results were compared for the four cohorts. Results: Both VPS and regular examination results were significantly higher in the VPS group compared to regular exam group (p < 0.001) in terms 1, 2 and 3. The paired mean difference in term 4 was 0.66 (95% confidence interval (CI) 0.50, 0.83; p < 0.001) for haematology and 0.57 (95% CI 0.45, 0.69; p < 0.001) for cardiology. Conclusion: Our findings suggest that using VPS both for learning and for assessment supports learning. VPS are better than traditional assessment methods when the virtual application is used for both learning and evaluation.

Virtual patient simulation: Knowledge gain or knowledge loss?

Background: Virtual patients (VPs), high-fidelity simulators and standardized patients are powerful educational interventions leading to effective learning and supporting knowledge retention. Aim: This study explored the variations in retention with VP versus regular learning activities. Method: We conducted a randomized controlled study on early and delayed assessment results of 49 students using VP for learning and examination of haematology and cardiology topics in an Internal Medicine course, by means of a 0–10 scoring rubric. Results: The mean difference for early assessment with VP (study – control mean score) was 1.43 (95% confidence interval (CI) 0.96, 1.91; p < 0.001) for haematology and 1.34 (95% CI 0.93, 1.76; p < 0.001) for cardiology. In regular exams, the mean score difference was 2.21 (95% CI 1.3, 3.1; p < 0.001) and 1.52 (95% CI 0.76, 2.28; p < 0.001), respectively. With delayed assessments, the difference in mean score for Web-SP was 1.48 (95% CI 1.09, 1.86; p < 0.001), haematology and 1.16 (95% CI 0.74, 1.58; p < 0.001), cardiology; for regular exams the figures were 1.96 (95% CI 0.93, 2.98; p < 0.001) and 1.74 (95% CI 0.89, 2.58; p < 0.001). The effect size ranged from 0.5 to 0.8. Conclusion: Our results indicate better retention with VP than with traditional learning methods.

Evaluation of a web-based ECG-interpretation programme for undergraduate medical students.

BackgroundMost clinicians and teachers agree that knowledge about ECG is of importance in the medical curriculum. Students at Karolinska Institutet have asked for more training in ECG-interpretation during their undergraduate studies. Clinical tutors, however, have difficulties in meeting these demands due to shortage of time. Thus, alternative ways to learn and practice ECG-interpretation are needed. Education offered via the Internet is readily available, geographically independent and flexible. Furthermore, the quality of education may increase and become more effective through a superior educational approach, improved visualization and interactivity.MethodsA Web-based comprehensive ECG-interpretation programme has been evaluated. Medical students from the sixth semester were given an optional opportunity to access the programme from the start of their course. Usage logs and an initial evaluation survey were obtained from each student. A diagnostic test was performed in order to assess the effect on skills in ECG interpretation. Students from the corresponding course, at another teaching hospital and without access to the ECG-programme but with conventional teaching of ECG served as a control group.Results20 of the 32 students in the intervention group had tested the programme after 2 months. On a five-graded scale (1- bad to 5 – very good) they ranked the utility of a web-based programme for this purpose as 4.1 and the quality of the programme software as 3.9. At the diagnostic test (maximal points 16) by the end of the 5-month course at the 6th semester the mean result for the students in the intervention group was 9.7 compared with 8.1 for the control group (p = 0.03).ConclusionStudents ranked the Web-based ECG-interpretation programme as a useful instrument to learn ECG. Furthermore, Internet-delivered education may be more effective than traditional teaching methods due to greater immediacy, improved visualisation and interactivity.

The use of a virtual patient case in an OSCE-based exam - A pilot study

Background: This study focuses on a skills test based clinical assessment where 118 fourth-year medical students at the four teaching hospitals of Karolinska Institutet participated in the same 12-module OSCE. The goal of one of the twelve examination modules was to assess the students’ skills and ability to solve a virtual patient (VP) case (the ISP system), which included medical history taking, lab tests, physical examinations and suggestion of a preliminary diagnosis. Aims: The primary aim of this study was to evaluate the potential of a VP as a possible tool for assessment of clinical reasoning and problem solving ability among medical students. The feeling of realism of the VP and its possible affective impact on the students confidence were also investigated. Method: We observed and analysed students’ reactions, engagement and performance (activity log files) during their interactive sessions with the simulation. An individual human assistant was provided along with the computer simulation and the videotaped interaction student/assistant was then analysed in detail and related to the students’ outcomes. Results: The results indicate possible advantages of using ISP-like systems for assessment. The VP was for instance able to reliably differentiate between students’ performances but some weaknesses were also identified, like a confounding influence on students’ outcomes by the assistants used. Significant differences, affecting the results, were found between the students in their degree of affective response towards the system as well as the perceived usefulness of assistance. Conclusion: Students need to be trained beforehand in mastering the assessment tool. Rating compliance needs to be targeted before VP-based systems like ISP can be used in exams and if such systems would be used in high-stake exams, the use of human assistants should be limited and scoring rubrics validated (and preferably automated).

Clinical reasoning in nursing, a think-aloud study using virtual patients - A base for an innovative assessment

In health-care education, it is important to assess the competencies that are essential for the professional role. To develop clinical reasoning skills is crucial for nursing practice and therefore an important learning outcome in nursing education programmes. Virtual patients (VPs) are interactive computer simulations of real-life clinical scenarios and have been suggested for use not only for learning, but also for assessment of clinical reasoning. The aim of this study was to investigate how experienced paediatric nurses reason regarding complex VP cases and how they make clinical decisions. The study was also aimed to give information about possible issues that should be assessed in clinical reasoning exams for post-graduate students in diploma specialist paediatric nursing education. The information from this study is believed to be of high value when developing scoring and grading models for a VP-based examination for the specialist diploma in paediatric nursing education. Using the think-aloud method, data were collected from 30 RNs working in Swedish paediatric departments, and child or school health-care centres. Content analysis was used to analyse the data. The results indicate that experienced nurses try to consolidate their hypotheses by seeing a pattern and judging the value of signs, symptoms, physical examinations, laboratory tests and radiology. They show high specific competence but earlier experience of similar cases was also of importance for the decision making. The nurses thought it was an innovative assessment focusing on clinical reasoning and clinical decision making. They thought it was an enjoyable way to be assessed and that all three main issues could be assessed using VPs. In conclusion, VPs seem to be a possible model for assessing the clinical reasoning process and clinical decision making, but how to score and grade such exams needs further research.