Sunday, June 11, 2006

Virtual Patients -- Pacer or Porsche?

Back in the stone ages when I was a medical student, we learned how to take a patient history by, well, sitting down with a real live patient and figuring it out on our own. There was a very large public hospital affiliated with the school, and there was never a lack of patients to see. We had role models, to be sure -- primarily the interns, but also the more senior residents and occasionally even the attendings -- and some were better role models than others. We did have "standardized patients" only for one day -- the tricky, awkward experience of learning how to do pelvic exams.

I would say that my classmates and I got good at taking histories (the first step in trying to figure out what is ailing a patient) and doing physical exams because we had to, as the volume of patients we were intended to see dictated a need for efficiency. We each learned the most effective way to accomplish the task that suited our own personality and personal skills. As we progressed through the 3rd and 4th years of school, that skill became second nature, and served us well as we progressed into residency. I would also say that the H&P process for me has continued to evolve, as I learn more about myself and about how best to interact with certain types of people. Most of the time, it's (almost) as fun of a process (for me) as surgery.

Apparently, my medical school experience is not reproducible today, for a large number of reasons. Students are not thrown into the water not quite knowing how to swim, and they are not generally expected to follow large numbers of patients during their clinical rotations. Ah, well, progress. They still need, however, to learn the ropes when it comes to communicating with patients -- and where there's a need, there will be somebody who is smart enough to try to meet that need. Some members of the Association for Surgical Education came up with the idea of computer generated, interactive patients to help students learn these skills, and published their findings in this month's American Journal of Surgery: The use of virtual patients to teach medical students history taking and communication skills

In the virtual scenario, a life-sized VP (virtual patient) is projected on the wall of an examination room. Before the virtual encounter, the student reviews patient information on a handheld tablet personal computer, and they are directed to take a history and develop a differential diagnosis. .... The VP is programmed with specific answers and gestures in response to questions asked by students. The VP responses to student questions were developed by reviewing videotapes of students'’ performances with real SPs (standardized patients). After obtaining informed consent, 20 students underwent voice recognition training followed by a videotaped VP encounter.

Initially, the VP correctly recognized approximately 60% of the student'’s questions, and improving the script depth and variability of the VP responses enhanced most incorrect voice recognition. Student comments were favorable particularly related to feedback provided by the virtual instructor. The overall student rating of the virtual experience was 6.47 ± 1.63 (1 = lowest, 10 = highest) for version 1.0 and 7.22 ± 1.76 for version 2.0 (4 months later) reflecting enhanced voice recognition and other technological improvements. These overall ratings compare favorably to a 7.47 ± 1.16 student rating for real SPs.
Of course, an old codger like myself would say the students compared the virtual patients favorably in comparison to standardized patients because they had not yet had the chance to interact with real patients! Sort of like driving a Porsche in a video game compared to driving a real AMC Pacer --- when the real Porsche is in the garage with the keys in it, waiting for you to take it for a spin!

Don't get me wrong -- I'm not a Luddite, and certainly think that anything that can help students become better communicators, and therefore better physicians, is a good thing. Other virtual learning experiences, particularly in surgery, have come into wider use in recent years. I guess I would be more inclined to push medical students to overcome their inhibitions, their shyness, their natural desire to avoid looking stupid, and have them interact with real live patients. The information that was gathered by the student's history and physical was valued in my learning experience, so I felt that I had a role to play in the patient's care, rather than being an interested bystander. Today's medical students should feel the same way.