has great potential as
a powerful tool for teaching reasoning and decision-making skills in
competency-based training. Virtual patients (VPs) are a form of educational game ,
these skills in medicine and healthcare training. St George’s University of
London (SGUL) have created a generic ‘model’ for VP design, simple to use, yet
flexible enough to simulate real decision-making.
For each VP an ideal pathway is described,
with 3-4 critical points that control progression through the case. To navigate
between nodes, a map of different interconnected possibilities is designed,
with 3-4 steps and 3-4 choices at each step, mimicking the choices
of a real
As a result, a simple
model can be used to create ergonomically designed
educational games. Other forms of competency-based training
could use the same
techniques. Possible applications for educational games such as VPs
include interactive problem-based learning tutorials, m-learning, and
Computer simulations have been used to support the development of competencies, skills, and critical thinking for many years (Wild, 1996; Malone, 1981; de Jong, 1991). Within medical and healthcare education, the use of simulated patients provides an excellent tool by which to learn and practice clinical competency (Bergin & Fors 2003). Broadly, simulated patients can either be physical or virtual models. Physical models, generally referred to as patient simulators, teach clinical skills. Virtual models – or virtual patients - are tools for teaching clinical reasoning.
A virtual patient is defined as: “an interactive computer simulation of real-life clinical scenarios for the purpose of medical training, education, or assessment.” (Ellaway, Candler et al., 2006). In its simplest form a VP allows the user, usually via a computer, to make a choice based on some presented information. The user is then given feedback dependent on their choice. More complex VPs will offer more choices, and then link pages together, so that the information and choices available at any stage depend on the choices made earlier in the scenario.
Although virtual patients address the needs of medicine and healthcare disciplines, they are essentially problem-solving exercises – the user must apply knowledge to make decisions and progress through the scenario (Henderson, 1998). This model is applicable to any discipline where the user needs to practice reasoning and decision-making skills. Decision-making and problem-solving are core skills reflected in all aspects of learning. Many vocational courses can find use for modelling real-life scenarios within a virtual world – law students can practice a court case; an architect can test their design choices; project managers can practice running an effective project.
Practising application of knowledge and skills within a virtual environment can offer some advantages over learning through real-life practice including:
Simulators and games such as VPs have proven effective and popular e-learning tools (Aldrich, 2005; Quinn, 2005) that can underpin and extend current practice in teaching and learning.
In order to be successful, VPs need to be as close to real practice as possible, whilst still offering educational opportunities and activities. It is emulating real practice that makes the design of decision-making games such as VPs a challenging task.
In a survey of 107 medical colleges in Canada and North America, half of virtual patients constructed had cost between 10,000-50,000 dollars, and many cost more than 100,000. In addition, the median time for VP production was 17 months (Huang, 2006). Not surprisingly, only a few of the medical schools were currently producing them.
Within the medical education community, there are four distinct approaches to virtual patient design.
· The linear approach: The principle of this approach is that the user is prevented from going down any wrong paths by immediate correction. This is often unrealistic for emulating real life, where there are often several ways to tackle a problem and mistakes are often not immediately obvious. This approach might be used for testing knowledge of a protocol, but will not engage students in the same way as more complex, multi choice scenarios.
· The algorithm method: Here formulae are developed that mimic physiologic processes in the body and in disease states, so that changes made by the user (typically administration of drugs or fluids) alter the output of the formulae and produce changes on the display, typically of biophysical variables. Some early computer modelled examples were produced at McMaster University, such as MacPuff, MacDope, MacMan (Dickinson et al. 1973). Most of clinical medicine cannot be tackled in this way, as it is descriptive and history based, and has limited transference to other disciplines.
· The Lo-Fi method: Here effort is spent on creating a large, but limited number of choices. Users are allowed to make around 2-3 wrong choices sequentially before finding out their mistake. They are given the option, after making a wrong choice, of making the correct choice, as long as the choice was not dangerous. These cases are often not as media-rich or as interactive as hi-fi cases. The interaction will focus on a specific set of options rather than a much broader set of choices. An example of a lo-fi VP is Sarah-Jane, developed at St George’s University of London.
· The Hi-Fi approach: This approach demands a large amount of time, money and effort to model all of the possible choices. Effort is then spent on linking the case to other media and on the appearance of the case. Simulators such as those simulated patients used to train emergency medicine staff and anaesthesiologists are becoming more available, although their purchase price and running costs are large.
The effectiveness of a decision-making game depends largely on choice. If a scenario has 3 choices at each level, within just 4 levels there have been over 100 pathways that the user may have chosen. Most clinical encounters will involve over 20 choices so perfectly realistic simulation becomes near impossible to model.
At SGUL the Lo-Fi approach has been used to develop
cases that offer
engagement for the user to actively practise clinical reasoning and
knowledge, whilst remaining practical to produce in terms of time and
budget restrictions – an effective compromise between realism and
practicality. The Lo-Fi approach also
– difficult to teach in other parts of a curriculum – rather than
SGUL have developed a 10-step model for Lo-Fi VP creation to limit the exponentially increasing number of choices needed at each level, while still offering a realistic level of potential decisions that can be made.
Here you want a
scenario that needs evaluation,
ideally involving several steps. In medical education
examples might include a man with chest pain, a vomiting baby, a woman
with post menopausal bleeding etc. In other fields, a scenario could be
an architect being approached by a householder wanting a loft
extension, a lawyer with a client who has been assaulted, an accountant
with a deficit in his company accounts etc.
Key nodes are essential stages that act as a gateway to the next part of the case. This is a construct to limit the exponentially expanding number of choices during the case back to one. There will typically be 3-5 nodes in a case, and they will represent the start of a stage of the patient’s management – for instance they might be triage in A+E, completion of resuscitation, admission to the ward, cardiac catheterisation and discharge home for a patient with a myocardial infarction.
This does not have to be the only way through the case, but will give the number of steps that will need to be programmed. There should be 3-4 between each node. This limitation is again a device to restrict the potential number of situations between each node, as for each correct choice there will need to be some other choices, each of which will then lead onto other choices. The steps to this stage are shown in figure 2 below:
Figure 2: Nodes interconnected to form an ideal pathway
These will represent the various scenarios within the case and the choices connecting them. It is important that they are placed empty within the emerging VP, as another device to manage the number of situations that the patient will go through in the case. You will need at least 100 pages in total to represent a reasonable case (see Figure 3).
Figure 3: An empty node map of a VP
Here you will need to think what might be
reasonable in a real situation, and use this as the basis for
naming the choices. The pattern of empty boxes (stage 4) might not
allow a representation of real life
pattern can also be readjusted with
boxes added or removed where essential. Further connections may
also be made at this stage, including alternative routes through
Dead end branches need an explanation and redirection back to an earlier node or to the start.
A logical and short numbering system is needed. In our cases 0 starts the case, and the next stage or step is 1, then 2 etc. Each situation at each stage is assigned a letter alongside: 2a, 2b etc. Dead end explanation pages are given the suffix ‘_e’ beside the page they are associated with: 4b_e for instance.
This is the way the case writer communicates with a technologist to describe the text at each situation, the choices and the names of the situations that selecting a particular choice will direct the user to. This part of the process is the most laborious, requiring imagination to create the narrative describing each situation.
This can be done simply by creating individual html pages, for instance in Dreamweaver or even MS Word, creating an XML schema, developing a suitable Flash player, or using another application, such as Labyrinth (see below: ‘Technical Development’).
The skeleton of the case is now complete. Depending on time and resources, the case can now be complemented with other features – clinical photography, video, or sound. It can be linked to other sources of information, such as on-line course materials and relevant websites.
This approach will typically produce a case of 10 steps, containing 120-150 pages. Approximately 10 hours is required to create such a case for one individual working alone.
SGUL has adopted a set process for the technical development of VPs following on from the 10-step creation model. Two open source software systems are used:
· Visual Understanding Environment (VUE) developed by the University of Tufts;
· Labyrinth developed by the University of Edinburgh.
VUE is an information management application that provides an interactive, concept mapping interface, allowing a node map of the case to be quickly emulated.
Labyrinth is an experimental educational pathway authoring and delivery system. It has an easy to use interface, and requires no prior programming knowledge. It incorporates the latest technical standards for electronic virtual patient simulations developed by MedBiquitous, a consortium of international medical schools and technical developers.
VUE and Labyrinth are complementary tools, with files created in VUE easily imported into Labyrinth. Each box in VUE becomes a page in the case and each arrow becomes a link. Labyrinth supports many different multimedia file types for the inclusion of sound, audio or video. Labyrinth allows the VP author to include timing of play, if desired, or to have scoring attached, with choices having different positive or negative weightings. Similarly ‘counters’ can also be set to increase or decrease with each step of the case – for example the patient’s heart rate. The user can review their pathway at any point, to look back and reflect on the choices they have made.
Finished cases can be played directly from Labyrinth, displaying as a collection of web pages that can be accessed through any online browser. Alternatively Labyrinth generates the virtual patient through an XML schema that can be exported out and used with other supporting VP players.
Figure 5: Example of a virtual patient played in Labyrinth
Our next steps will be to evaluate VPs. A pilot study for replacing paper-based problem based learning tutorials with virtual patients is due to begin in Autumn 2007. SGUL’s current 4yr PBL-based medical curriculum will be replaced in part with a VP curriculum, in order to engage the learner with a more interactive and less linear learning scenario.
There is also interest in using VPs for
inter-professional working. VPs can allow the student to gain
an insight of what it is to work within an inter-professional
team, by allowing the user to interact with the same patient
from a variety of professional perspectives. Alternatively,
of different professions throughout the course of the
patient’s story can be easily demonstrated.
VPs are also suitable for use in distance learning and disseminated learning courses. Several distance learning courses will be trialing VPs in their curriculum over the 2007/08 Academic year. Novel ways of VP delivery – such as playing the VP through Second Life will also be trialed.
Finally, we are exploring the use of virtual patients as tools for both formative and summative assessment, particularly in later years of education, with a scoring system reflective of the pathway chosen by the candidate.
scenarios that reflect real-life situations
make the development of high-quality, effective resources
demanding. Currently the number
of freely available VPs in medical education is low. With the
advance of easier models for VP design, shared practice, and
pooling of resources within the e-learning community (for
example see the EC funded eViP project),
the number of VPs available for teaching will rise.
These resources have
the potential to be used in a variety of settings, including
testing reasoning, decision-making skills, knowledge, and
problem-based learning. One of the main obstructions to using
games such as VPs in education, is the lack of evidence in
supporting their use (de Freitas, 2007). At SGUL our next
steps are to evaluate the use of VPs within the medical and
healthcare curriculum in order to try and evaluate the
different applications for VPs as teaching and learning tools.
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