Restrepo 1 Virtual Patients in Medical Schools

Simulation advances are affecting everyone around the world and often, in a beneficial way. The use of computer programs is becoming a great part of education and universities are using resources such as ebooks and online portals. Clearly higher education students are expected to know how to use computer programs and be able to adjust to other programs once they become professionals. I have had the chance to visit UCFs College of Medicine and I have seen, first-hand, the impact computers and simulation has had in higher aspects of education. Although UCF COM is rather new and therefore started out as a highly technological medical school, there have been older institutions that have recently changed the way they teach their students. I have come across several articles discussing the benefits of teaching medical students with different types of computerized simulation, such as Virtual Patients, which have been describes as An interactive computer simulation of real-life clinical scenarios for the purpose of healthcare and medical training, education or assessment (consorti 2012). Advances in technology make life easier and it is interesting to see how these advances make an impact in medical schools. This bibliography will explore different studies that show the benefits, as well as the negative of using VPs in medical education. The scope of these journals show if students learning increases with the help of virtual patients. There are also journals explaining the use of VPs in different specialties such as geriatrics, and how the VPs help with learning. Several studies will demonstrate how well recieved virtual patients are and whether they can improve cognitive and behavioral skills better than traditional methods do. Also many of these journals are foreign, but still apply to the general medical student. Many journals come from the Medical Teacher journal which is a journal that specifically deals with subjects about teaching medical students.

Restrepo 2 Berman, Norman B., Leslie H. Fall, Alexander w. Chessman, Michael R. Dell, Valerie J. Lang, Shou Ling Leong, L. James Nixon, and Sherilyn Smith. A Collaborative Model for Developing and Maintaining Virtual Patients for Medical Education. Medical Teacher 33. (2011): 319-324. Web.

Berman and her team, all medical doctors developed a seven point model that they hope will be used as a guide in implementing VPs in other medical schools or health sciences schools. They claim that successful development of VPs requires an understanding of how they are adopted and integrated in medical schools, so they proposed this model. The seven key components of this model are (1) comprehensive coverage of a nationally accepted curriculum, (2) collaborative multi-institutional authoring, (3) a consistent pedagogical approach, (4) resources for integrating the program in the curriculum, (5) maintenance of the content, (6) support for the academic needs of medical educators, and (7) a support infrastructure. These are explored more in depth in the journal, but they conclude by explaining how difficult it is to have an agreement on curriculum, the need for a comprehensive curriculum is a challengeand achieving consensus on a curriculum across national borders is even more difficult (Berman et. Al 2011). They do believe however that this model is empowering medical educators with a greater impact on medical education by having them develop the methodology needed to deliver their curricula, which would be a positive outcome for medical students.

Botezatu, Mihaela, Hakan Hult, Mesfin Kassaye Tessma, and Uno G. H. Fors. Virtual Patient Simulation for Learning & Assessment: Superior Results in Comparison with Regular Course Exams. Medical Teacher 32. 10 (2010): 845-850. Web. Mihaela Botezatu and her colleagues are all doctors based in Sweden. They traveled to a medical school in Bogota, Colombia to study the use of virtual patients in medical school. Their study aimed to observe the differences in assessment results between virtual patient simulation (VPS) and

Restrepo 3 regular course exams in an Internal Medicine course for undergraduate medical students. The program that they used to test is Web-sp an interactive virtual patient. The participants of this study were 4 groups of students which were randomized into either a study group that used Web-Sp or a control group. Then these two groups were divided into students studying hematology or cardiology. After taking examinations in each respective category, it was found that students using Web-Sp on average got higher scores than those just using paper case studies.

Cendan, Juan and Benjamin Lok. The use of virtual patients in medical school curricula. Advances in Physiology Education 36. 1(2012): 48-53. Web. Although technology has risen in all aspects of education in the past years, Cendan Et al. argue that few medical schools have added virtual patients to their curriculum. In fact, they mention that only 24% of medical schools in the US and Canada had been using VPs in their curricula in 2007. In this journal entry they explain what exactly VPs are. VPs are computer programs that stimulate real-life clinical scenarios. These include just case studies in in web pages or CD_ROMS, Virtual reality simulation, or robotic human scale mannequins. They write that, simply stated, VPs are a computer-based simulation of a patient and are typically composed of three components: inputs, simulation, and outputs. They explain that the biggest reason why not many medical schools have added VPs to their curriculum is because of their cost. The high-fidelity human scale mannequins require technical support during activities and they bring storage and maintenance cost, not including what they cost alone.

Consorti, Fabrizio, Rosaria Mancuso, Martina Nocioni, Annalisa Piccolo. Efficacy of Virtual Patients in Medical Education: A Meta-Analysis of Randomized Studies. Computers & Education 59. 3 (2012): 10011008. Web.

Restrepo 4 Fabrizio Consorti and his team are part of the Department of Cardiocirculatory Pathophysiology, Anestesiology and General Surgery of the Faculty of Medicine University Sapienza of Rome. They stated that VPs can provide a way to reduce student access to real patients, as well as a structured and safe environment for students to practice. They stated that VPs are becoming very popular but that their efficacy is still a matter of debate. This is a meta-analysis that summarizes evidence from randomized studies that compare the effect of VPs when they are used as an alternative method or as an addition to the curriculum. This is a meta-analysis, so the methodology was carried out by searching already existing articles about virtual patients. They searched for articles about graduate or undergraduate medical education, which reported the use of VPs as a teaching method and assessing their efficacy with respect to an educational outcome. They also excluded studies without a control group or with a nonrandomized design. The results showed that VPs are effective; the main indication was that VPs are effective toward many different specific educational outcomes like clinical reasoning, clinical data gathering and interpretation.

Couteille, O., R. Bergin, D. Stockeld, S. Ponzer and U. Fors. The Use of a Virtual Patient Case in an OSCEbased Exam A pilot study. Medical Teacher 30. (2008): e66e76. Web. Couteille, Bergin STockeld, Ponzer and Fors all work in for the Karolinska Institutet in Sweden and they specialize in Educational technologies. The aim in conducting this study was to evaluate how well a VP would work as a tool for assessment of clinical reasoning and problem solving ability in medical students. The study was conducted in May 2004 during the Objective Structured Clinical Examinations OSCE procedure at the surgery course of the five and a half-year long medical program at Karolinska Institutet. The OSCE are used to determine a students ability to conduct and examination in order to figure out the diagnosis, as well as suggest treatment. Usually these would be conducted with standardized patients (human actors) but for the purpose of this study, students were observed while

Restrepo 5 they interacted with actor patients as well as VPs. The students were divided into four groups. The 110 students that participated all volunteered, which showed that they were enthusiastic about the VPs. However the outcome of the study was not favorable. Most students were not able to finish each VP station on time, and in one case one of the groups only got an average of 40% correct diagnosis. Couteille et al. believe that if the students trained beforehand VP cases can be a useful complementary tool for assessing some of the many components of clinical competence, including clinical reasoning skills.

Edelbring, Samuel, Olle Brostrom, Peter Henriksson, Daphne Vassiliou, Jonas Spaak,Lars Owe Dahlgren, Uno Fors and Nabil Zary. Integrating Virtual Patients into Courses: Follow-up Seminars and Perceived Benefit. Medical Education 46. (2012): 417-425. Web. Samuel Endelbring and the rest of his team agreed that although VPs have had very promising results, they are not as widely used as they should be. They state that more knowledge is needed regarding aspects of integrating VPs into a course, of which student acceptance is one key issue (Endelbring et al. 2012). They developed a cross-sectional explanatory study which was performed at four teaching hospitals. The VP related activities were collaboratively planned by all the teachers in the four hospitals. However, each setting employed a different strategy to follow-up the activity in the course. Questionnaires were distributed at each hospital pertaining to perceived benefits of VPs and such. Students that were part of the more intense follow up activities seemed to favor the VPs more than students in the intermediate and low intensity follow ups. The findings suggest that a more intense follow-up pays off in terms of the benefit perceived by students. This journal proved that VPs should be used as a holistic course instead of just a supplement.

Restrepo 6 Gesundhiet, Neil, Pauline Brutlag, Patricia Youngblood, William T. Gunning, Nail Zary and Uno Fors. The Use of Virtual Patients to Assess the Clinical Skills and Reasoning of Medical Students: Initial Insights on Student Acceptance." Medical Teacher 31.8 (2009): 739-742 Academic Search Premier. Web. 2 Oct. 2012 Neil Gesundheit and his colleagues are all medical professors, most of them at Stanford University where this study was conducted. The goal of this study was to find how easily accepted virtual patients would be in a medical school. They introduced a certain type of VP, the Web-SP, to 15 second year and 12 fourth year medical students. The second year students participated in both a standardized patient exam (an SP is a human actor that portrays symptoms) and a VP exam. Both exams were on the same subject area, in this case neurological disease, but they were two different cases. The fourth year students were only given the VP exams. Students were asked to fill out exit questionnaires about their experiences for both the standardized patient and VP exams. Also students participated in a focus group at the end of the testing session to provide detailed comments about the VP. Students showed a high level of acceptance of the web-SP. In the surveys and discussions students said that the VPs were realistic, appropriately challenging, and rated the study as a valuable learning experience.

Harris, David M., Kathleen Ryan, and Cynthia Rabuck. Using High Fidelity Patient Simulator with First Year Medical Students to Facilitate Learning of Cardiovascular Function Curves. Advances in Physiology Education 36. 3 (2012). Web. David Harris, Kathleen Ryan and Cynthia Rabuck conducted a study in which they introduced high fidelity patient stimulators to first year medical students in order to see if these would help them understand CV function curves better than just lecture and notes. They conducted this study to two first year classes, one in 2009 and another in 2010, both in Drexel University College of Medicine. High fidelity patient stimulators are realistic mannequin-like stimulators that respond to IV fluids and

Restrepo 7 medications.. HFPS are introduced to clinical medical students, which are students in their third and fourth year. In this study the students were given a six question pretest and a 6 question posttest before and after the activity. After the activity there was an increase in the amount of people that got all the answers right, there was also an overall increase of 21% in scores from the pretest to the posttest. Harris, Ryan and Rabuck write that the majority of students agreed that the Simulation Center activity helped them to learn CV function curves, the role of cardiac mechanics in congestive heart failure treatment strategy, and the Frank-Starling law of the heart which is the most important fact of this study. Along with this they write that students disagreed with the statements about being overwhelmed, that the simulation activity was too long, and that they would have preferred to stay in their small groups. To make sure this study had an effect on these students, four months after the conclusion of this study the students were given a survey in which they rated the simulation; most students rated it as good or excellent. Overall students agreed with the fact that the simulation activity helped them learn some basics.

Hilton, Sean, Terry Poulton, Emily Conrandi, Sheetal Kavia, and Jonathan Round. "The Replacement of 'Paper' Cases By Interactive Online Virtual Patients In Problem-Based Learning." Medical Teacher 31.8 (2009): 752-758. Academic Search Premier. Web. 22 Oct. 2012.

Sean Hilton and his team work at Saint Georges University of London. SGUL has a problem based curriculum using paper-based patients. Emily Conradi is the e-Projects Manager for the e-Learning Unit at St Georges University of London and she is responsible for several grant funded VP projects. In this case they wanted to counter the limitation that paper cases allow. These paper cases are linear and do not allow students to explore the consequences of decisions. Interactive online virtual patients (VPs)

Restrepo 8 were developed and they allowed students to consider options as the cases unfold, and allow students to explore the consequences of their actions. The basic problem based learning paper cases were transferred into the visual understanding environment (VUE developed by Tufts University), allowing a case to be quickly drawn out using simple boxes and links. Students were then introduced to branched cases, which were the VPS and linear cases (paper cases). This went on for about five weeks, with one new case each week. At the end 29 surveys were filled out and 75% of these stated that they preferred the branched cases (VPs). They explain that the main advantages were seen by the students to be the ability to make decisions and explore the consequences. VPs were seen as a success by students and tutors.

Huang, Grace, Robby Reynolds, Chris Candler. Virtual Patient Simulation at U.S. and Canadian Medical Schools. Academic Medicine 82. 5 (2007):446-451. Web.

Grace Huang is an instructor of medicine at Harvard Medical School, Robby Reynolds and Chris Candler are both directors in Division of Medical Education, Association of American Medical Colleges, Washington, DC. They conducted this study because they wanted information on the development of virtual patients in medical schools in the US and Canada. They did this because despite persuasive evidence VPs are not as widely use as people would think. They conducted their study by contacting curriculum deans at 142 US and Canadian medical schools and asked them to report on VP simulation activities in their schools. The reports included questions such as technical platform (CD-ROM, DVD-ROM, Internet based), intended audience (students, resident trainees, faculty, or allied health professionals), feedback mechanism, user setting (individual or group) among others. The study had a 76% response rate and 82 out of these responded

Restrepo 9 that they did not use VPs in their curriculum. This journal goes more in depth explaining the responses of each report. They concluded that more development of VPs in medical schools would allow medical schools to enhance their clinical curricula.

Huwendiek, Soren ,Friedrich Reichert, Hans-Martin Bosse, Bas A de Leng, Cees P M van der Vleuten, Martin Haag, Georg F Hoffmann and Burkhard Tonshoff. Design principles for virtual patients: a focus group study among students. Medical Education 43. (2009): 580588. Web.

Huwendiek and his team wanted to examine what students perceive as the ideal features of virtual patient (VP) design. In this study, four cases were presented to students via the simulative presentationmode. A total of 104 5th year medical students participated in this study at the Faculty of Medicine, Heidelberg University. The students rotated through the 4-week program meeting at the four weekly VP sessions that were held. Each VP activity was then followed by a 30 minute discussion of the case. At the end of the program, focus groups were formed and the discussions were videotaped. These vidoetapes were then analyzed and major themes and topics of discussion were grouped. The team then found that according to the students, learning is facilitated when VPs are relevant, are of appropriate difculty, and are interactive. Tan, Zaldy s., Paul L Mulhausen, Stephen R. Smith and Jorge G. Ruiz. Virtual Patients in Geriatric Education. Gerentology and Geriatrics Education 31. 1(2010):163-173. Web. Zaldy Tan and his team are all part of medical schools across the country, Zaldy Tan and Jorge G. Ruiz specializing in geriatrics. They write that in 2007 there were only 7,128 physicians certified in geriatric medicine and this number is projected to increase by less than 10% by 2030 while the

Restrepo 1 0 population of elderly will double to 70 million in 2030. He mentions that in order to meet the need for training the entire health care workforce to be competent in caring for older adult patients, alternative teaching methods must be explored. At Harvard and Iowa universities geriatric VPs have been used. In the University of Iowa, GeriSims, which is a type of VP, have been used since 2003. They cover nine areas of geriatric care: delirium, dementia, failure to thrive, falls, functional assessment, ischemic stroke, palliative care, polypharmacy, and urinary incontinence. The VP is a potentially useful educational medium for case-based learning and assessment that has been successfully used by several geriatrics education programs (Tan et al. 2010). To conclude this journal they added that VPs are very useful for geriatric care.