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ICVP-Conference - Krakow June 5th, 2009 1

Virtual patients: From pragmaticimplementation to educational research

and back Martin Fischer, MD, MME (Berne)

Institute for Teaching and Educational Research in Health SciencesMedical Faculty

Private University Witten/[email protected]

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Circumstances matter1989 until now

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http://rcpsc.medical.org/canmeds/index.php

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We have done it like

this for a long timeWhy change?

Show me the data.

What is the evidence?

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ICT and Learning: Instruction vs.construction

Valcke & De Wever 2005

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What is a virtual patient?

A virtual patient has been defined as "aninteractive computer simulation of real-life

clinical scenarios for the purpose of healthcare and medical training, educationor assessment" (Ellaway, Candler et al.,2006).

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8/46ICVP-Conference - Krakow June 5th, 2009 8JAMA 2009

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in concluding that Internet-based learning iseducationally beneficial and can achieve resultssimilar to those of traditional instructional methods.

Cook et al. JAMA 2009

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Elucidating how to effectively implementInternet-based instruction will be answered mostefficiently through research directly comparingdifferent Internet-based interventions.

Cook et al. JAMA 2009

2193 studies identified

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Best Evidence Medical Education(BEME)A legitimate child of Evidence-based Medicine

Best evidence medical education (BEME) is theimplementation, by teachers in their practice, of methods and approaches to education based on

the best evidence available.

It involves a professional judgement by theteacher about their teaching taking into account

a number of factors []

Harden 1999

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BEME: Q U E S T SA multi-dimensional approach

1. Q uality: How good is the evidence?

2. U tility: To what extent can the method be transferred anadopted without modification?

3. E xtent What is the extent of the evidence?

4. S trength How strong is the evidence?

5. T arget What is the target? What is being measured? Howvalid is the evidence?

6. S etting? How close does the context or setting approximatHow relevant is the evidence?

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Harden et al. Medical Teacher 1999

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Medical EducationResearch

Those who cant do teach. Those who cant teach

teach how to teach. Those who cant teachhow to teach do research

on teaching.adapted from Bernhard ShawThe doctor's Dilemma 1906

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Winner of the 50.000 Karolinska InstitutetAward for Excellence in Research into MedicalEducation.

Who will be next?

R. HardenGP, Endocrinologist

Scotland

H. SchmidtPsychologistNetherlands

G. NormanEpidemiologist & Statistician

Canada

A VP-researcher from Europe?

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More research needed...

Descriptive studies (What wasdone?)

Justification studies (Did it work?)

Clarification studies (Why or how did

it work?)H. Schmidt, AMEE 2005

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And the distribution is

110 articlespublished in 2003 and 2004 inAcad MedicineAdv in Health Sciences Education

American J of Surgery J of General Internal MedicineMedical Education

Teaching and Learning in Medicine

75 (72%) justification studies17 (16%) description studies13 (12%) clarification studies

Cook, Bordage & Schmidt; Med. Educ. 2008

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Adding subtitles

Localization (medical documentation)

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Credits drives case use

0

50

100

150

200

250

300

350

20.05.2004 27.05.2004 03.06.2004 10.06.2004 17.06.2004 24.06.2004

Psychology, n=3009

Internal Med I, n=939

Internal Med II, n=18Tuesday

Sessions

Hege et al. 2007

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Learning by teaching: law FacultyLMU

Students create their own case in smallteams in a tutorial context with assistance of a content expertCredits for completed case (after

presentation)Status quo: 33 cases (21 peer reviewed)created by 45 studentsPromising acceptance, motivation andsuccessIntegration of the cases into the curriculumafter review

Hege et al. 2007

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Voluntary use and a case-basedexam

200 students attend an integrated PBL course(rheumatology, emergency med., orthopedics,traumasurgery).

10 exam-related cases are provided asvoluntary learning tool.Exam case (paper/online)

High acceptance

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Assessment drives the case use

0

50

100

150

200

250

300

350

400

25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0

Summerterm 03

Winterterm 02/03

Sessions

Days prior to exam

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Combining VPs

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Clinical skills online CAU &LMU: Blended Learning

Karsten et al. 2009

Face-to-face: Course physical examination

Summative assessment - OSCE

Typical cases plusbasics Skills lab training

Questions for formative self-assessment

Case (1):Introduction of

Patient

Theoreticalbasics

Presentation &Explanation

of skills

Case (2):Cont. &

finish

Questions for formative self-assessment

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Obstetrical skills CTG-interpretation

high-fidelity

low-fidelity

high-fidelity

low-fidelity

2

4

6

8

10

12

*

5

10

15

20

*

A B

High- versus Low-Fidelity

Scholze, Jenderek et al. 2009 (submitted)

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Induction of fetal lung maturity anddelivery after 48 h

Oxytocin i.v. to accelerate contractions

Ventouse extraction

Immediate delivery by cesareansection

CT-scan to exclude pulmonary embolism

1

2

3

4

high-fidelity

low-fidelity

5

6

Obstetrical decision making

Maternal paramters HR: 115 bpmNIBP: 105/60 mmHgRR: 25 bpmTemp.: 38.2 oC

Pelvic examination Dilatation: early effacementPresentation: Vertex; LOAStation: -4

Plan

28 (1G/0P) 34.5 weeks of gestation.Estimated fetal weight on 10th percentile.lower UTI - treated withAmocixillin (500mg, po, tid) since 24h

History

CTG

x

High- versus Low-Fidelity

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Worked examples: learning fromerrors

Objective: fostering medical students` diagnostic knowledge:conceptual knowledgestrategic knowledgeconditional knowledge

Worked examples with errors versus without errors

Errors as learning opportunities (Oser, 2005), but: errors needto be understood to foster learning

Elaborated feedback versus knowledge of result (KOR-)feedback

Elaborated feedback facilitates understanding in complexdomains

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Design & Instruments forAssessing diagnostic knowledge

Conceptual knowledgeMultiple-choice (MC) tests, 23 items

Strategic knowledge10 key-feature problems

Conditional knowledge3 problem-solving tasks

Feedback format

elaborated KOR

Example format

with errors n = 38 n = 38

without errors n = 39 n = 37

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Results for Arterial hypertension

Main effect error: p < .05, Interaction effect: p < .01

40

42

44

46

48

50

with errors without errors

elaboratedFeedback

KOR

Kopp et al. 2008

S

c o r e

( p o

i n t s )

N = 153 medical students

Findings replicated for hyperthyroidismSustained effect in the field

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Session Manager Learning Systems

Holzer et al. 2005

From CASEPORT

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to the eViP Project

http://www.virtualpatients.eu

3-years project co-funded by the EuropeanUnion until Sept. 2010, 4 systems, 9 partners

Aims

Creating large international repository of virtual patientsSharing/exchanging of virtual patientsRepurposing of virtual patientsImplementation of virtual patients into thelocal medical curricula

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ICVP-Conference - Krakow June 5th, 2009 37www.ims-m.de

Item-banking and VP-systems

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Theory-grounded

vs.pragmatic approaches?

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Quantitative

vs.Qualitative?

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Interprofessional

andInter-institutional?

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ICVP-Conference - Krakow June 5th, 2009 42http://www.gmc-uk.org/education/index.asp

Room for improvement

Finally, although our findingsregarding the quality of thisbody of research are notunique to research inInternet-based instruction,therelatively low scores for methodological quality andthe observed reporting

deficiencies suggest room for improvement.

Cook et al. 2009

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More challenges to do research on

e-Learning/virtual Patients Peer-assisted learningCommunicationInterprofessional learningSimulationsAssessmentFaculty developmentProfessionalismStudent selectionMentoringCME/CPD

.

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Perspectives

More research on case-basedlearning needed (from VPs to realpatients and back)Integration of learning assessmentFostering interdisciplinary andinterinstistutional approaches

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Outcomes: Improving patient care!

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Many thanks!

[email protected]

Documents

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