Virtual Patients Deliver Real Learning

By Norm Berman, MD

Just as the US health care system is at a critical juncture, so is the system of medical education. Medical education needs to change, not only to keep pace with a rapidly changing health system, but to drive change by better educating the next generation of providers to create a transformed health care system. Virtual patients (VPs) can play an important role in the transformation of medical education, and can produce the real learning required to facilitate change.

What are virtual patients? Simply put, VPs are interactive clinical case scenarios delivered using computer technology, these days almost exclusively over the Internet. Although VPs have been around since before the Internet, their use has grown steadily in recent years. Clerkship directors across disciplines have embraced VPs; virtually all US clerkships in pediatrics, internal medicine, family medicine, and surgery are now using them. Use of VPs extends across the world, and beyond medical student education to all of health care education.

There are sound reasons why. The virtual patients that are used most commonly in the United States were developed through a novel collaboration of national medical educator organizations and a non-profit – MedU – that is devoted to VP development and maintenance. A study of pediatric clerkship directors conducted by Schifferdecker et al. in 2007 found that the collaborative development process was a major factor in their decision to begin using these VPs in their clerkship. A survey of internal medicine clerkship directors conducted by Lang et al. in 2009 and again in 2011 showed that although meeting LCME requirements was a major driver initially, by 2011 the purpose shifted to improving learning. In the 2014-15 academic year, medical students will complete more than 1 million MedU virtual patient cases!

One student wrote, “[Virtual patients] were an excellent learning tool, one of the best I’ve used in med school so far. I loved all the links, the videos, etc. I found I was able to engage my curiosity as I learned, rather than simply memorize. They took a while, but it was really worth it, and I picked up several great resources that I think I will use in my clerkships, residency, and practice.” Teaching faculty report, “[Students] see actual cases and work through them and have to apply knowledge versus just memorizing facts,” and “[The program] leads trainees through the experience of histories and physicals, and actual differential diagnoses, and investigations, so that was well thought out. The links to additional resources were well placed and essentially it was a nice product in terms of creating a believable experience.”

In many ways, virtual patients can be superior to real patients in medical education.

Teaching and assessing clinical reasoning. There is good reason to believe that VPs are an ideal way to teach clinical reasoning, the hallmark of physician practice. Summary statements are a manifestation of clinical reasoning, and MedU incorporates summary statements in most virtual patient cases. Work performed over the past year by a multi-institutional group of MedU collaborators is aimed at training software to score student summary statements, using machine learning techniques. Pilot testing shows this to be feasible, and this work will be launched as a beta version at selected medical schools in the 2015-16 academic year. With this innovation in operation, students will receive structured feedback on their work, without adding to the already heavy workload of teaching faculty.

Assessing and improving learner competence. Preliminary data from 18 medical schools show that students who complete more virtual patient cases during their clerkships perform better on their end-of-clerkship exams. Self-assessment is another critical component of active and self-regulated learning and VP software can readily incorporate self-assessment. In recent work led by MedU collaborator Martha Seagrave, PA, a national group of family medicine educators paired with medical students at several medical schools to develop additional self-assessment questions based on the content of the virtual patient cases. These self-assessment questions were used by thousands of medical students over the past year, and have performed very well.

Encouraging students’ cognitive engagement. To encourage engagement and real learning with assigned VP cases, MedU developed an “engagement meter,” which is displayed to students as they are working through cases. Software was developed to analyze student actions in the VP cases that reflect actual cognitive engagement. Data presented at the 2014 AAMC meeting show that this has been very effective, producing real positive changes in how students interact with online cases. Research performed over the last year and presented at the 2015 COMSEP annual meeting by MedU collaborators Carrie Phillipi, MD, PhD, and Lynn Foster-Johnson, PhD, demonstrated a significant correlation between student engagement and completion of self-assessment questions.

Inter-professional and interdisciplinary education. Many of the most important clinical problems in health care today require an interdisciplinary approach. Topics like population health and addiction medicine have often been difficult to fit into the traditional medical school curriculum. MedU has partnered with the American College of Physicians to develop a course in High Value Care, based on the ACP’s successful resident curriculum. The Josiah Macy Foundation, the American Board of Internal Medicine Foundation, and the Alliance for Academic Internal Medicine supported development of this important course. A course on Addiction and Recovery Education, CARE, was developed in a collaboration between MedU and the Hazelden-Betty Ford Foundation in 2014; an expanded course with six cases and 12 engaging video lectures is being launched in July.

Analyzing educational data. Large amounts of educational data are being created by the broad implementation of VPs. Learning analytics and educational data mining techniques can be applied across a large number of students and institutions to assess educational gains, and VP-based learning data can now be used to predict success or failure in other domains. Further, educational data can be used to create a feedback loop that results in virtual patients that create more real learning.

Virtual patients are a reality in medical education today, and their broad use is producing the real learning that is needed to improve health care education and our health care system. The innovations discussed here are only the beginning: The rapid advances in technology and our understanding of learning offer even more promise in the years to come.

Berman NormNorm Berman, MD, is Professor of Pediatrics at the Geisel School of Medicine at Dartmouth; and Executive Director and Co-Founder of MedU. He can be reached at norm.berman@med-u.org.

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