Learning Real Medicine in a Virtual World: Using Simulation to Integrate Essential Critical Thinking and Communication Skills Lynn Crespo, Ph.D. Assistant.

Learning Real Medicine in a Virtual Learning Real Medicine in a Virtual World:World:

Using Simulation to Integrate Using Simulation to Integrate Essential Critical Thinking and Essential Critical Thinking and

Communication SkillsCommunication SkillsLynn Crespo, Ph.D.

Assistant Dean, Medical Education

College of Medicine

Our New Home Our New Home Opening Spring 2010Opening Spring 2010

04/19/23 3

biochem

The Building Blocks of MedicineThe Building Blocks of Medicine

anatomy

genetics

pharmmicro

clinical med

pathology

doctoring

physiology

biochem

immuno

A Better Way to Build!A Better Way to Build!

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Putting it All TogetherPutting it All Together

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Intro to Profession of Medicine ( 1 wk)

Elective

Elective Elective

Neurology (6)

Cultural Medicine

Service Learning

Med/Surg AI

Feb Mar

Elective

Elective Elective

Elective Elective

Elective

Elective

Elective/Research/Study Elective/Research/Study Elective/Research/Study Elective/Research/StudyElective/Research/Study

Elective

Pediatrics (6)

JulJun

Med/Surg AI

Critical Care Critical Care Critical Care

ER ER

Neurology (6)

Pediatrics (6)

Med/Surg AI

Elective

Neurology (6) Neurology (6) Neurology (6) Neurology (6) Neurology (6)

Pediatrics (6)

Elective/Research/Study

Elective

Elective

Elective Elective

Other Core AI Other Core AIOther Core AI

Elective Elective

Medical Imaging

I-1 Focused Individualized Study and Research

Aug

C-1 Psychosocial Issues in Healthcare (3 wks +)

Vaca

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M-2

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Diag

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Clin

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Pro

blem

Sol

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wee

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S-3 Cardiovascular and Pulmonary System (6 wks)

Nov Dec

Community of Practice

HB-1 Human Body: Molecules to CellsBiochemistry, Cell Biology, Genetics,

Molecular Biology, and Preclinical Informatics (8 wks)

Nov

Vaca

tion

S-2 Endocrine, Reproductive, and Genitourinary System

(6 wks)

S-1 Hematology/Oncology (3

wks)

C-1 Psychosocial Issues in Healthcare ( cont'd, 11 wks)

HB-3 Human Body: Health and Disease

Microbiology, Immunology,

Virology, Intro to Pathology (cont'd,

4 wks)

HB-3 Human Body: Health and Disease

Microbiology, Immunology,

Virology, Intro to Pathology (4 wks+)

HB-2 Human Body: Structure and Function

Anatomy, Embryology, Radiology, Physiology, Histology,

Neurobiology (cont'd, 7 wks)

Jan

IS M

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MayP-1 Practice of Medicine

HB-2 Human Body: Structure and FunctionAnatomy, Embryology, Radiology, Physiology, Histology, Neurobiology ( 10 wks +)

Apr

Oct

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tone

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erie

nce

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Neurology (6)

Pediatrics (6)

Jan Feb Mar Apr

MayAprMarFebJan

M-1

New

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dent

Orie

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Elective

Elective Elective

Other Core AI

Sep

Nov

Elective Elective Elective

Elective Elective Elective

S-4 GI/Hepatic and Renal System (6 wks)

Pediatrics (6)Pediatrics (6)

Critical Care Critical Care

Med/Surg AI Med/Surg AI

Other Core AI Other Core AI

M1

Critical Care

M2

ER

Med/Surg AI

P-2 Practice of Medicine

Aug Sep

Elective/Research/Study

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Elecitve

Elective/Research/Study

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Critical Care

Elective

ER ER ER ER ER

Med/Surg AI

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Elective

Critical Care

Gra

duati

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Critical Care

Med/Surg AI

Other Core AI

Elective

ER

Critical Care

Gender Based Medicine

Medical Informatics

Medical Spanish

Capstone Experience: Leadership, Teaching,

Prep for Internship

Interview/Vacation

Elective

Elective

Community of Practice (include nutritional service WIC, Elder care etc.)

Med/Surg AI

Other Core AI

Vacation

Pediatrics (6)

May

Apr

Longitudinal Curricular Themes

Medical Nutrition

Geriatrics

Pallative Care

Patient Safety

Ethics & Medical Humanities

OB/Gyn (6)

OctSepAug

NBME Prep

Feb

I-2 Focused Individualized Study and Research

Dec

Mar

OB/Gyn (6) OB/Gyn (6)OB/Gyn (6)OB/Gyn (6)OB/Gyn (6)OB/Gyn (6)OB/Gyn (6)

Psychiatry (6) Psychiatry (6) Psychiatry (6) Psychiatry (6)

Oct Dec

IS M

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S-6 Neurologic Systems (6 wks)

S-5 Skin and Musculoskeletal System (4 wks)

Pediatrics (6)

Internal Medicine/Family Medicine (12)

Internal Medicine/Family Medicine (12)

Internal Medicine/Family Medicine (12)

Vac

ation

Surgery and Surgical/Other Selectives (12) Surgery (12) Surgery (12) Surgery (12) Surgery (12) Surgery (12)M3

Ori

enta

tion

to

Cler

kshi

ps Internal Medicine/Family Medicine (12)Internal Medicine/Family Medicine

(12)

Prof

essi

onal

ism

, Eth

ics,

Co

mm

unic

ation

Internal Medicine/Family Medicine (12)

Psychiatry (6) Psychiatry (6) Psychiatry (6) Psychiatry (6)

Interview/Vacation Interview/Vacation Interview/Vacation

Other Core AI

ElectiveElective

Elective/Research/Study

Elective

Elective Elective

Nov Dec Jan

Prof

essi

onal

ism

, Eth

ics,

Com

mun

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Vac

ation

Interview/Vacation Interview/Vacation Interview/Vacation Interview/Vacation Interview/Vacation

M4

Jun Jul Aug Sep Oct

Interview/Vacation

Elective/Research/Study

Med/Surg AI

Other Core AI

Poor Quality of Care & Medical Errors:Poor Quality of Care & Medical Errors:Contributing FactorsContributing Factors

Integrated application of knowledge through critical thinking

Poor communication skillsLack of compassionHidden biases

Knowledge, Skills, Attitudes and Knowledge, Skills, Attitudes and BehaviorsBehaviors

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Learning ModalitiesLearning ModalitiesStandardized

Patients

AdvantagesSafe, controlled environment

Limitations•Limited opportunities for practice•Limited pool of patients•Delayed feedback•Expensive

Lecture

AdvantagesEfficient transfer of knowledge

LimitationsLow fidelityLack of ability to demonstrate communicationNo skills training

Virtual Patient

Advantages•Repetitive practice•Standardized•Exposure to many populations•Immediate feedback•Safe practice environment

LimitationsCase DevelopmentProgramming

Mannequin

Advantages•Procedural skills•Immediate feedback for decisions

Limitations•Poor communication skills training•Expensive•Greatest learning follows debriefing

Clerkship & Internship

AdvantagesReal patients

Limitations•Limited opportunities for practice•Negative role modeling possible•Delayed or missing feedback

““Real Medicine in a Virtual World”Real Medicine in a Virtual World”

Goal 1: Improve communication skills with patients

Goal 2: Recognize and overcome biases Goal 3: Integrate basic science and

clinical reasoning across curriculum Goal 4: Monitor and develop critical

thinking skills

The ChallengeThe Challenge

Multiple presentation modalities with different technology and informational requirements.

Document Based (Level 1)• Text• Pictures• Video

Virtual Case (Level 2)•Patient appearance•Patient interview

Mixed/Immersive (Level 4)• Multiple stages, technologies•High coordination

Standardized Patient/Human Patient Simulator (Level 3)

•Scripts•Interactive•Setting•Technology

Case

•Objectives•Difficulty•Capstone•Integration

Strategic PlanStrategic Plan

Innovative use of simulation in undergraduate medical education.

Avatar patient will be managed across his/her lifespan across 4 year curriculum

Clinical skills – basic science integration– Continuity of care through contingencies– Proactive/Preventative medicine (patient empowerment)– Student motivation and interactivity– Supports long term memory storage and retrieval– Leverages narrative/digital storytelling

Sickle Cell Capstone CaseSickle Cell Capstone Case

Patient AGE

Patient Health Episodes

3

EPISODE 1• sore knee• fatigue

EPISODE 2• Upper respiratory infections

EPISODE 3

EPISODE 4Myocardial Infarction

EPISODE 5Dementia, cancer, et…

7 80505

Benefits of Capstone CasesBenefits of Capstone Cases

Simulate longitudinal factors across the lifespan

Compare alternative treatments and self correct

Assessment of decision making skills transfer

Emphasize physician-patient relationship

Fosters integration

Motivation – we tend to think in narrative

Simulatior Applications for Clinical Simulatior Applications for Clinical CasesCases

Virtual People Factory Web-SP

Human Patient Simulator

Standardized Patient

Virtual Patients for Medical Virtual Patients for Medical School CurriculaSchool Curricula

VPF development supported by University of Florida Alumni Fellowships and National Science Foundation Grant IIS-0643557

COLLABORATORS AND COLLABORATORS AND SUPPORTERSSUPPORTERS

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What is VirtualPeopleFactory?What is VirtualPeopleFactory?

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Interactive web-based tool– Create virtual patients– Interview virtual patients– Assess VP encounters

Developed at UF– Brent Rossen, Dr. Ben Lok

What is VPF used for?What is VPF used for?

Interpersonal skills– Knowing what to ask – Addressing patient concerns– Empathy and rapport

Critical thinking skills– Diagnosis

Basic science knowledge

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Advantages of VPFAdvantages of VPF

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24 hours/day availability on the web– Additional practice and feedback

Scenario diversity– Abnormal findings– Diversity training

Standardization Semi-automated student assessment

Interviewing a VPInterviewing a VP

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Simulation of SP encounter Go to web page Freeform conversation

– Student types questions– Patient answers

naturally Realistic patient behavior

– Patient challenges

Patient: “Doctor, my mother had breast cancer. Do you think my pain could be because I have cancer?”

Student: “What seems to be the problem?”Patient: “I found a mass in my breast, and I’m really worried about it.”

Feedback and AssessmentFeedback and Assessment

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Transcripts2009-03-23 12:40:31

Anonymous said: how long has your breast hurt Amanda Jones replied: i guess the pain started a couple months ago. i've just been trying to ignore it

2009-03-23 12:40:44

Anonymous said: can you describe the pain for me Amanda Jones replied: it's kind of a dull pain, it's really sensitive to the touch though

2009-03-23 12:40:54

Anonymous said: on a scale of 1 to 10, how would you rate the pain Amanda Jones replied: i don't know, maybe a four

2009-03-23 12:40:57

Anonymous said: is it always a four Amanda Jones replied: i know what they are, but i've never had one

2009-03-23 12:41:05

Anonymous said: does the pain change Amanda Jones replied: the pain started before my period and it still hurts, so i didn't think it could be related

2009-03-23 12:41:16

Anonymous said: does the pain spread to anywhere else Amanda Jones replied: no

Feedback and AssessmentFeedback and Assessment

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Critical Information Gathered

Feedback and AssessmentFeedback and Assessment

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Interview Organization

Face ValidityFace Validity

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Faculty feedback– “Easy to use with relatively little training”– “Worthwhile because it can be used over and

over”– “Provides an alternative for students to learn

history-taking skills”Students

– Multiple uses– Some students – over an hour

Over 1600 VPF interactions to date

SummarySummary

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Web-based virtual patientsBased on SP encountersAdditional practice on

– Interpersonal skills– Diverse patients– Critical thinking– Basic Science

Summary, cont’dSummary, cont’d

Delivers– Frequent practice– Diverse scenarios– Standardization– Automated assessment

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AcknowledgementsAcknowledgements

UCF College of Medicine

Medical Education Faculty

Dr. Moshe Feldman Dr. Laura Cuty-

Ruiz

Collaborators

Brent Rossen – Creator of VPF

Dr. Benjamin Lok – Supervisor

Dr. Carole Kimberlin, Dr. Diane Beck, Hevil Shah, Aaron Kotranza, Joon Chuah, Dr. Kyle Johnsen, Dr. D. Scott Lind, Dr. Juan Cendan.

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