ePoster
Abstract Title | Evolution of the Use of On-Line Virtual Patients in the Internal Medicine Clerkship

Authors

  1. Valerie J. Lang MD; Jennifer Kogan MD; Norman Berman MD; Darrio Torre MD PhD

Theme

Virtual Patients and eCase Studies

Category

Virtual Patients

INSTITUTION

University of Rochester, University of Pennsylvania, Dartmouth Medical School, Drexel University

Background

The apprenticeship model has remained the dominant learning activity in clinical clerkships for the past 100 years, supplemented by classroom activities and self-directed reading. On-line virtual patients (VPs) are an innovation which has rapidly diffused to teach medical students.  Despite the significant resources required to develop and maintain VP programs, little is known about why and how this innovation has been adopted.

Conclusion

Rogers' diffusion of innovation theory (4) and Kern and colleagues' systems approach to curriculum development in medical education (5) provide conceptual frameworks for interpreting the results of our study.  Diffusion of innovations theory describes 5 steps in the diffusion-decision process:  knowledge, persuasion, decision, implementation, and confirmation.(4,p169) Knowledge and persuasion were supported by  the collaborative process of developing the VP program.(6) Early adopters may have implemented the VPs and found that their assumptions were confirmed, resulting in the sustained importance of VPs in meeting cognitive learning objectives.  Late adopters or "laggards" may have had different goals, placing less emphasis on LCME requirements.(4,p283-4) Kern and colleagues describe a 6-step systems-based model of curriculum development in medical education.(5) Our study provides insight into the first three steps of Kern’s model; by understanding the needs, goals, and objectives for which VPs are adopted, clerkship directors can make more informed choices about how they implement virtual patients within the broader clerkship curriculum.  Prior studies have shown improved student satisfaction and perceived learning value when VPs are systematically integrated into clerkship curricula.(7,8)

Take-home Messages

Meeting cognitive learning objectives and regulatory requirements are important reasons for adopting VPs, though goals may change as the innovation is more widely diffused.  Clarifying goals is an important first step in more systematically integrating VPs in clerkship curricula.

Summary of Work

In 2009 and 2011, 110 U.S. internal medicine clerkship directors were surveyed regarding their adoption of Simulated Internal Medicine Patient Learning Experience (SIMPLE) VPs, including meeting national Core Medicine Clerkship Curriculum learning objectives (3), Accreditation Council on Graduate Medical Education competencies, and Liaison Committee on Medical Education (LCME) requirements (2), and accommodating changes in the learning environment.  In 2011 respondents were also asked how they implemented VPs in their curricula. 

Summary of Results

 

Responses were obtained from 69 (63%) of the 110 clerkship directors in 2009, and 86 (78%) in 2011.   In 2011, 8 (21%) replaced a learning activity with VPs, 9 (24%) integrated VPs into other learning activities, and 21 (55%) simply added VPs onto their curricula.

   

Acknowledgement

The authors wish to thank the Clerkship Directors in Internal Medicine for assistance in administering and completing the surveys.

References
Background

A seminal meta-analysis of VP studies found that they are an effective method for teaching medical knowledge, clinical reasoning, and other skills.(1) The Liaison Committee on Medical Education (LCME) specifically notes that virtual patients may be used to meet ED-2 requirements which require faculty to define the types of patients and clinical conditions students must encounter and ensure that all students have these experiences.(2)  The ED-2 requirement overlaps with ED-8, which stipulates that students training at different clinical sites must have similar experiences.(2)

Conclusion
Take-home Messages
Summary of Work

We performed chi-square tests and Fishers Exact tests (where n<5) to compare responses between the 2009 and 2011 survey. We considered a p value < 0.05 to be significant.

Summary of Results

Table.  Clerkship directors’ purposes for using SIMPLE virtual patient cases, 2009 and 2011.  Data reflect the number of respondents who selected each item as somewhat or very important.  LCME = Liaison Committee on Medical Education.  “ED-2” = Educational Program Requirement number 2.  “ED-8” = Educational Program Requirement number 8. 

 

 

2009

 n (%)

2011

n (%)

p-value

Total Respondents

33

45

 

Improve Student Outcomes

 

 

 

Knowledge base

29 (88)

40 (91)

1

Developing a differential diagnosis of common medical problems

27 (82)

38 (86)

0.96

Identifying key findings from the history, physical, and data

26 (79)

38 (86)

0.73

Developing a basic management plan for common medical problems

27 (82)

34 (77)

0.38

Meet Additional ACGME Competencies

 

 

 

Communication skills

6 (18)

5 (11)

0.48

Professionalism

7 (21)

5 (11)

0.29

Systems-based practice

10 (30)

10 (23)

0.36

Practice-based learning and improvement

10 (30)

13 (30)

0.85

Meet LCME Requirements

 

 

 

Meet LCME ED-2 requirements (in general)

31 (94)

33 (73)

0.011

   Compensate for variable patient numbers

25 (76)

18 (40)

0.001

   Compensate for variable diagnoses seen

28 (85)

27 (60)

0.004

Compensate for variability in clerkship sites or subspecialty services (ED-8)

25 (76)

25 (56)

0.04

Accommodate Changes in Learning Environment

 

 

 

Compensate for decrease in available faculty

11 (33)

6 (14)

0.02

Improve students' exposure to patients with undifferentiated problems

24 (72)

33 (75)

0.85

Add outpatient cases to inpatient clerkship

15 (45)

12 (27)

0.07

Add inpatient cases to outpatient clerkship

8 (24)

4 (9)

0.06

Acknowledgement
References

1.    Cook DA, Erwin PJ, Triola MM.  Computerized virtual patients in health professions education:  A systematic review and meta-analysis.  Academic Medicine.  2010;85:1589-1602.       

 

2.      Liaison Committee on Medical Education.  Functions and structure of a medical school:  Standards for accreditation of medical education programs leading to the M.D. degree.  June, 2010.  http://www.lcme.org/functions2010jun.pdf.  Accessed April 14, 2011

  3.   DeFer TM, Fazio SB, Eds.  CDIM-SGIM Core Medicine Clerkship Curriculum Guide, version 3.0. 2006.  http://www.im.org/toolbox/curriculum/Students/Learning/Pages/CDIM-SGIMCoreMedicineClerkshipCurriculum.aspx. Accessed May 31, 2012.  

 

             4.   Rogers EM.  Diffusion of Innovations, 5th Ed.  New York:  Free Press, 2003.

 

5.      Kern DE, Thomas PA, Howard DM, Bass EB.  Curriculum development for medical education:  A six-step approach.  Baltimore: Johns Hopkins University, 1998.

6.      Berman NB, Fall LH, Chessman AW, Dell MR, Lang VJ, Nixon LJ, Smith S.  A collaborative model for developing and maintaining virtual patients for medical education.  Medical Teacher. 2011;33(4):319-324.

7.      Berman N, Fall LH, Smith S, Levine DA, Maloney CG, Potts M, Siegel B, Foster-Johnson L.  Integration strategies for using virtual patients in clinical clerkships.  Acad Med.  2009;84:942-949.

8.      Edelbring S, Brostrom O, Henriksson P, Vassiliou D, Spaak J, Dahlgren LO, Fors U, Zary N.  Integrating virtual patients into courses:  Follow-up seminars and perceived benefit.  Med Educ.  2012;46:417-425

 

 

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