By Martin Warters, MA, CHSE; Keno Vigil; Pamela Peters, PhD, Medscape Education
The first known collection of medical information resides on a single small clay tablet found in what was originally Sumer, site of the earliest known human civilization. Contrast that single tablet with the vast — and growing — volume of medical information today: In 1950, it was estimated that the amount of medical knowledge had doubled in the previous 50 years; in 2010, doubling time was 3.5 years, and it’s estimated that doubling time in 2020 will be only 73 days.[i] So much information means that physicians have ever more therapeutic options, but they also must make more choices than ever before, and some of those choices will be incorrect. We’ve all heard that practice makes perfect, but it’s not always feasible to “practice” in medicine, as incorrect choices can hurt, or even kill, patients.
Simulation in Medical Education
Enter simulation-based learning — traditionally, the use of plastic models, standardized patients and other means to simulate patient care. Simulations play an important role in medical training and continuing professional development (CPD). Unfortunately, simulations do not often support the full range of critical thinking required in actual clinical practice. As a result, while traditional simulation modalities are effective means of knowledge transfer, they are not as effective in other learning arenas. In fact, studies show that learning modalities that are most likely to support critical thinking and transfer of knowledge into the practice setting are those that most closely resemble actual practice settings[ii] and that allow “learning through doing.”
With this in mind, and recognizing the importance of CPD, we set out to design a Virtual Patient Simulation (VPS) platform that supports full-spectrum critical thinking, clinical decision-making and translation of newly acquired knowledge into actual clinical practice. Our goal was to enhance achievement of best possible patient outcomes even as available data, guideline based practices, legal regulations and requirements, and patient characteristics change over time and over the course of physicians’ and other healthcare providers’ (MD/HCP) careers.
CPD relies on obtaining up-to-date information as it becomes available so that practitioners’ critical thinking skills, technical expertise and knowledge base stay current. It is clear that a wide variety of educational tactics, platforms and scenarios are capable of fulfilling the need for current knowledge acquisition. What is less clear is how — or even if — these tactics can support full spectrum critical thinking, the effective transfer of knowledge to the clinic and real-life clinical decision making. The question then becomes whether these skills can be brought to actual clinical practice more effectively by virtual patient simulation than by other means. Although sufficient data are not available to answer that question in relation to healthcare, there is a large body of data showing that virtual simulation in pilot flight training provides superior skills transfer, “situational awareness,” and actual in-flight performance as compared with other educational modalities. For example, Cohen reports a “…71 percent reduction in the number of [flight] accidents caused by [pilots’] poor decision making… [since] the introduction in the mid-1980s of realistic flight simulators.”[iii]
Therefore, our purpose was to develop, and continually optimize, the medical equivalent of a realistic flight simulator — a simulation model that is as close to the clinical setting as it can be without any possibility of harming a patient and with the goal and objective of improving patient outcomes. Toward that end, our VPS was developed to differ from other simulation strategies in that it allows MD/HCPs to practice realistic patient care in an environment that incorporates the most recent medical data and guidelines along with as many aspects of actual clinical care as possible, without the possibility of causing patient harm.
Characteristics of the VPS
The VPS was developed de novo with innovative, nontraditional features to create a simulation that resembles the actual clinical setting as closely as possible while maintaining a consequence-free environment in which learners are free to make mistakes without causing harm to actual patients. These features include:
- Full spectrum of patient care, with interactive video, from presentation to subsequent visits and follow up.
- Dynamic and persistent EHR interface, mirroring actual EHR functionality, which updates in real-time as the learner progresses through the simulation.
- Follows the workflow of real-life clinical practice and includes practice features such as a prescription pad, test orders, and realistic lab reports.
- Third-party drug database allows learner prescribing options in breadth and depth mirroring actual clinical practice.
- Learners’ clinical decisions are not limited by multiple choice, but rather are supported by a data and guideline based decision engine to allow the large range of choices and options that are available in true-to-life care to facilitate critical thinking and best replicate clinical practice.
- Learners’ decisions are evaluated against the most recent data and guidelines available, to address development of clinical reasoning skills over time as conditions and available information develop. In this way, analytical and clinical thinking and reasoning mature along with each learner’s experience and practice.
- Patient case workflow follows the same path and order of a real-life clinical encounter to support translation of learning into the clinical setting.
- A feedback engine provides both formative and summative feedback approaches to enhance learner understanding and to reinforce and promote, where applicable, behavior change, thus supporting optimization of patient outcomes.
- Learners can experiment with decisions in a safe, real-world-like environment to support increased confidence in practice aimed at reducing errors and improving patient outcomes through the process of active experimentation.
- Adult learners benefit from contextualization of their performance as compared to a standard. VPS learners are provided with data regarding their own achievements, as well as peer-to-peer rankings, to gauge personal performance and identify areas of needed improvement.
- Learners are provided with data and guidelines based clinical guidance (CG) feedback in response to their clinical decisions and are able to modify their decisions after receiving CG. Comparison of pre- and post-CG decisions provides information both to direct further educational opportunities and ongoing optimization of the VPS platform itself as well as to quantify educational impact.
Impact on CPD
This VPS provides a learning experience as close as possible to a real clinical setting with the added benefit enabling MD/HCPs — motivated adult learners — to experiment with decisions and practice clinical care without fear of harming real patients. The real-life complexity and level of clinical choice generated by the VPS are unique in their scope and provide a missing link between knowledge/competence and actual clinical performance. By facilitating development of critical thinking skills and emulating practice performance, this VPS furthers the field of CE/CPD through its EHR based, realistic, consequence-free clinic-like simulated practice environment and patient-care workflow.
Case study: Virtual Patient Simulation in HIV: An Online Educational Tool to Improve Evidence-Based Clinical Decision Making
Treatment options for patients with HIV are currently supporting life expectancies up to approximately 70 years. However, fewer than 50 percent of infected individuals are receiving regular care and only 25 percent are achieving viral suppression. This VPS intervention aimed to improve the ability of MD/HCPs who care for HIV positive individuals to identify candidates for antiretroviral therapy (ART) and to develop appropriate care strategies.
Over 22,800 MDs, NPs and RNs, including over 2,100 physicians who directly care for HIV-positive patients, participated in a VPS activity in which learners virtually cared for two different HIV-positive patients. After participation in this activity, these physicians showed significant improvements in a variety of areas including in baseline laboratory assessments, provision of preventive care and initiation of antiretroviral therapy. Equally importantly, analysis of learner data uncovered significant gaps and educational needs in a variety of areas including staging or HCV fibrosis/cirrhosis and timely initiation of ART for HIV infection. The depth of understanding of ongoing knowledge and practice gaps is made possible by the lack of multiple choice limitations in the VPS platform. The similarity to actual clinical practice of the VPS program is likely to increase the possibility that learnings will be translated into improved clinical decision making by clinicians who are caring for patient. A full description of this VPS study is available at https://img.medscapestatic.com/pi/edu/qrcode/posters/vps-in-hiv-an-online-educational-tool-to-improve-evidence-based-clinical-decision-making.pdf.
[ii]Cook DA, Brydges R, Zendejas B, Hamstra SJ, Hatala R. Mastery learning for health professionals using technology enhanced simulation: a systematic review and meta-analysis. Acad Med. 2013;88:1178-1186;
Gaba DM. The future vision of simulation in healthcare. Simul Healthc. 2007;2:126-135
[iii] Lehrer, J. (2009) How We Decide. Houghton Mifflin Harcourt. NY. pp 251-252. https://books.google.com/books?id=QEnjzV0rTvwC&pg=PA251&lpg=PA251&dq=71+percent+reduction+in+the+number+of+accidents+caused+by+%E2%80%9Cpoor+decision-making&source=bl&ots=3rOZf5hwH_&sig=FrwyA_ZSbIrtYl62Qp2WdXQiycA&hl=en&sa=X&ved=0ahUKEwilsYO9zpHXAhUMS2MKHQrJAz8Q6AEILjAB#v=onepage&q=71%20percent%20reduction%20in%20the%20number%20of%20accidents%20caused%20by%20%E2%80%9Cpoor%20decision-making&f=false Accessed 10/22/2017