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For airplane pilots, simulator training is a longstanding way of training. Taking over the responsibility for hundreds of people ten kilometers up in the air requires previous practice in a safe environment. In health professional education, simulated or standardized patients—humans trained to communicate characteristics of a specific disease—are used to practice clinical reasoning skills before entering practice itself. Also, real patients, suffering from a disease known by the teacher, can be asked to present their disease history to students during a lecture. However, these resources are not easy to obtain, so healthcare teachers turn to virtual patient simulators (VPSs) for practicing clinical decision making. Moreover, VPSs, like many e-learning resources, can be adapted to present various clinical pictures, and disease modules are quite easily to extend or to update.

As a recent example, medical educators from the University Hospital Cologne in Germany describe their experience with using an in-house built VPS in surgery lectures and small-group training. To foster VPS development and usage, Kleinert and colleagues offer free development of “custom modules” for other clinical conditions, provided the log files of the training with the VPS are handed over to them.

The VPS called ALICE (Artificial Learning Interface for Clinical Education) was embedded in a PowerPoint®-supported lecture1, replacing a real patient and adding interactive elements to the lecture format. When the VPS was plugged into the lecture, the screen showed a virtual clinic environment with a patient presenting her/his symptoms via a speaking bubble. Connected to the lecturer’s presentation through mobile devices (smartphone, tablet, or laptop), the students were asked to answer open or multiple-choice questions about the appropriate diagnostic and therapeutic decisions. The answers were embedded into the presentation, and, besides identifying the most appropriate answer, the lecturer also commented on the second and third most frequent answers. ALICE-accompanied lecturing in esophageal cancer almost doubled the number of correct answers (from a mean 27 out of 60 to 46) by the students about appropriate therapeutic workflows.

The ALICE developers also used the VPS to impart an “immersive” virtual patient experience to the students during a surgical seminar2 (one instructor for small groups of less than five students). Here the intended learning outcome was the application of correct standard operation procedures (SOPs) for different cases of esophageal cancer—selection of suitable medical tests, matching results with disease stages by diagnosis, and corresponding choice of therapies. First, the instructors handed over files from two real cases of esophageal cancer, and students (ignorant of the disease) were asked to write a clinical reasoning summary of their findings. Also, a multiple-choice test assessed the students’ pre-existing knowledge about the underlying disease. Afterwards, each student applied her/his) knowledge using ALICE. In the VPS environment, the students interacted through an avatar with other doctors, nurses, and the patient who simulated two different types of esophageal cancer. The students could request the medical history of the patient and select different types of medical examinations. Results were shown on the screen as tables, images, or videos (if ultrasound was selected). The performance of the students was assessed by a virtual instructor (based on stored SOPs). Eventually, the students re-assessed the cases given to them at the beginning and took the test about the disease again. The choice of right diagnosis and therapy increased from 65 to 92 and from 32 to 76 percent, respectively, showing a strong training effect of the VPS. Patient simulators such as ALICE, conclude the authors, are helpful to immediately translate obtained declarative into procedural knowledge. The training effect can presumably be amplified by iterative use of the VPS.

Two caveats are worth to mention. A VPS cannot (yet) help students show empathy and practice real communication, both essential for bedside practice. Also, the Kleinert et al. report that the students—tempted by the game-like user interface—tended to apply all available medical examination methods when using ALICE in the surgical seminar, although in this case their performance was downgraded. In any case, the ‘Generation Y’ grew up with digital and online content. As discussed in my previous blog post, the students of this generation are more motivated to learn, and presumably better at learning, if these preferences are respected in educational design. Accordingly, students learning with ALICE overwhelmingly stated that they had fun working with the VPS, and that it greatly supported the lectures as well as their learning experience.

Mirko von Elstermann

Read more: [1] Kleinert R, Plum P, Heiermann N, Wahba R, Chang DH, Hölscher AH, Stippel DL. Embedding a virtual patient simulator in an interactive surgical lecture. J Surg Educ. 2015 Dec 15. pii: S1931-7204(15)00287-1.

[2] Kleinert R, Heiermann N, Plum PS, Wahba R, Chang DH, Maus M, Chon SH, Hoelscher AH, Stippel DL. Web-based immersive virtual patient simulators: positive effect on clinical reasoning in medical education. J Med Internet Res. 2015;17(11):e263.

See also: Cook DA, Erwin PJ, Triola MM. Computerized virtual patients in health professions education: a systematic review and meta-analysis. Acad Med. 2010;85:1589-602.