Forum: Science & Society
Developing virtual patients for medical microbiology education David McCarthy1, Ciaran O’Gorman2, and Gerry J. Gormley3 1
46 White Glen, Derriaghy, Lisburn BT17 0XN, UK Centre of Medical Education, Queen’s University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast BT9 7BL, UK 3 Department of General Practice, Queen’s University Belfast, Dunluce Health Centre, 1 Dunluce Avenue, Belfast BT9 7HR, UK 2
The landscape of medical education is changing as students embrace the accessibility and interactivity of e-learning. Virtual patients are e-learning resources that may be used to advance microbiology education. Although the development of virtual patients has been widely considered, here we aim to provide a coherent approach for clinical educators. For medical education to be effective, both what we teach but how we teach it need to be informed and evidencebased. The delivery of microbiology curricula has been subject to criticism from students who feel overwhelmed by the abstract principles and microbial nomenclature being delivered using traditional lecture formats [1]. Student dissatisfaction with the teaching of microbiology and subsequent resentment towards the subject have been posited as a reason for superficial, assessment-driven learning as opposed to the development of a deeper appreciation and understanding of its relevance to clinical practice [2]. This failure of medical practitioners to engage fully in learning microbiology has consequences for patient care. It has been suggested that both medical students and doctors exhibit suboptimal application of microbiological principles in practice, such as adherence to hand hygiene procedures [3]. There is often a disconnect between what students are taught and how they apply this knowledge. Narrowing this theory–practice gap is a key objective for modern medical microbiology curricula. Therefore, it is vital to scrutinise how microbiology curricula are delivered. Are they accessible and relevant to students and are there any educational resources that could help improve student application of microbiological principles in practice? Learner and teacher acceptance in using e-learning resources has developed greatly. There is a developing trend whereby students appreciate the role of e-resources in complementing or even replacing other learning materials [4]. Despite the inherent difficulties in comparing e-learning resources with non-computer modalities [5], evidence is emerging that integration of e-learning Corresponding author: O’Gorman, C. ([email protected]). Keywords: virtual patients; e-learning; education; microbiology.
resources into microbiology education may improve examination scores compared to the use of traditional lecture formats [6]. Virtual patients (VPs) are one element in an expanding portfolio of e-learning resources. VPs are considered to be computer programmes that endeavour to replicate a safe clinical experience in which the student can assume a doctor-in-charge role while being guided through a clinical expert interpretation of the presentation, diagnosis, and treatment of key medical conditions [7]. VPs have pedagogic value in that they reactivate prior knowledge gained from earlier teaching (vertical integration) or other concurrent sources (horizontal integration), making it accessible as working memory to generate new knowledge. This reactivation and subsequent generation of knowledge can result in VPs being more effective facilitators of both shortand long-term memory retention when compared with traditional methods of teaching such as lectures and small group work [8]. VPs provide a secure educational environment in which students can learn from their mistakes before engaging with actual patients. This safe and forgiving space has been shown to result in students feeling more prepared for human interactions [4]. VPs can deliver a wider range of scenarios than may be encountered during bedside teaching, can readily link answers to the contemporary evidence base, and are cost-effective [9]. VPs complement a widely dispersed student population because they allow the study of materials regardless of student location, teaching staff availability, and patient accessibility [9].This has led to academic evaluation of repurposing of VPs, whereby these resources are shared on an inter-institutional and/or interdisciplinary basis to further improve their cost effectiveness. VPs also have unique potential in the development of clinical reasoning skills. Clinical reasoning involves acquiring, analysing, and integrating clinical information from various sources (e.g., patient history, examination findings, laboratory results and radiological investigations) into a diagnostic management plan. This does not equate to understanding the basic scientific principles involved in performing a skill (which can be taught via lectures, small groups, or computer-aided instruction) or the ability to perform it correctly (which can be taught using standardised patients or simulators in a clinical skills centre.) In the context of medical microbiology, clinical reasoning relates to appreciating when to perform a 613
Forum: Science & Society
Trends in Microbiology December 2013, Vol. 21, No. 12
clinical test and how to interpret the results meaningfully [5]. Clinical reasoning in expert practice becomes a nonanalytical and unconscious process of recognising patterns of presentation. The benefit of using VPs is that they can act as longitudinal case simulations that can reflect several doctor–patient interactions, and therefore provide a template for pattern recognition in future clinical encounters. In medical education there is emerging interest in blending simulation (including VPs) into curricula and evaluating the benefits of doing so. The literature shows a positive correlation between VP integration into medical curricula and student application of clinical skills in specialties such as haematology and cardiology [5,8]. However, despite research suggesting that e-learning resources can foster a positive attitude towards microbiology education [10], there is evidence that medical schools that developed VPs are reluctant to include a microbiology or immunology component [11]. Furthermore, there appears to be a paucity of research evaluating the use of these resources in microbiology education. We suggest that the potential for VP integration into microbiology curricula is currently underappreciated and propose that the roles for VPs in medical education support several of the core objectives [12] identified for microbiology and infectious disease curriculum development (Table 1). Although there is limited evidence relating directly to microbiology, the process of VP development more generally has attracted considerable attention. Thakore and McMahon proposed a four step process for VP development [13]: (i) Identify the educational objectives; (ii) Design the content; (iii) Build or create the multimedia materials relevant to the educational objective; and (iv) Integrate and evaluate the e-learning resource within the curriculum. To meet our educational objectives, we developed content related to common or catastrophic diseases, providing students with a spectrum of frequently encountered conditions while recognising the necessity of exposure to lifethreatening infections. The process of designing content and creating the supporting media has been considered by other authors [14,15]. With the modelling of clinical reasoning and the promotion of student satisfaction as our aims, we identified eight design features that were used to develop our microbiology VP suite for medical students in Queen’s University Belfast (Figure 1). Ethical approval was obtained from the School of Medicine, Dentistry and Biomedical Sciences Ethics Committee of Queen’s University Belfast. The VPs were developed for
Use content relevant to student's clinical experience Provide 'Doctor in Charge' experience
Use media student may encounter on ward
Blend of open quesons and mulple choice quesons
VP design features
Provide immediate feedback to answers
Probe for differenal diagnosis as case progresses
Ask for discriminang features of key condions
Describe probability and priorisaon of condions
TRENDS in Microbiology
Figure 1. Key design features for virtual patient (VP) design.
third-year medical students studying at Queen’s University Belfast, where an integrated spiralling curriculum has been adopted. The resource was distributed to all 278 students as distance learning materials to provide a curriculum-enhancing learning experience. In designing and creating the multimedia material, we integrated images, audio recordings, and videos to faithfully replicate the results of various investigations and examinations alongside commonly encountered hospital charts. In all instances, the relative importance of the media was emphasised through immediate feedback that related back to the presentation, differential diagnosis, and treatment to help inform the decision-making process. Video S1 in the supplementary material online shows how we integrated these features into a microbiology VP resource. Our overall intent was for students to simulate autonomous clinical practice, modelling the doctor-in-charge role. Video S1 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.tim.2013.10.002. In conclusion, microbiology VPs are an underappreciated tool in the medical educator’s toolbox. In today’s world, the majority of medical students can and do access e-resources from a range of devices. Whether in the classroom, at home, or on the ward, VPs allow students to interact with clinically relevant content that is challenging, informative, and
Table 1. How VPs can help deliver the objectives of microbiology medical education Objective Review course material
Familiarise students with differential diagnosis Show the relevance of basic science
614
Desired outcomes Understand how viruses, bacteria, and fungi cause disease Know the names and virulence strategies of the major clinical pathogens Know which pathogens infect which specific organ systems Generate a differential diagnosis Be familiar with the diagnostic approaches to infectious diseases Integrate facts related to microbiology and infectious disease and apply them to specific patients Choose an appropriate anti-infective therapy
Forum: Science & Society consistent. From a resource perspective, VPs are a costeffective reproducible e-learning resource that can model the fundamentals of clinical experience while fostering student confidence in a safe learning space. We believe that VPs are tools that encourage both clinical reasoning and student satisfaction and thus are closely aligned to our needs as educators of infection medicine. References 1 Beylefeld, A. and Struwig, M. (2007) A gaming approach to learning medical microbiology. Med. Teach. 29, 933–940 2 Osborne, J. et al. (2003) Attitudes towards science: a review of the literature and its implications. Int. J. Sci. Educ. 22, 1049–1079 3 O’Brien, D. et al. (2009) Survey of teaching/learning of healthcareassociated infections in UK and Irish medical schools. J. Hosp. Infect. 73, 171–175 4 Balasubramaniam, C. et al. (2009) Repurposing existing virtual patients: an Anglo–German case study. Bioalgorithms Med. Syst. 5, 91–98 5 Cook, D. and Triola, M. (2009) Virtual patients: a critical literature review and proposed next steps. Med. Educ. 43, 303–311 6 Desai, N. et al. (2000) Infection control training: evaluation of a computer-assisted learning package. J. Hosp. Infect. 44, 193–199
Trends in Microbiology December 2013, Vol. 21, No. 12 7 Association of American Medical Colleges (2007) Effective Use of Educational Technology in Medical Education: Summary Report of the 2006 AAMC Colloquium on Educational Technology, Association of American Medical Colleges 8 Botezatu, M. et al. (2010) Virtual patient simulation: knowledge gain or knowledge loss. Med. Educ. 32, 562–568 9 Boye, S. et al. (2012) An e-learning course in medical immunology: does it improve learning outcome? Med. Teach. 34, e649–e653 10 O’Neill, E. et al. (2011) Use of e-learning to enhance medical students’ understanding and knowledge of healthcare-associated infection prevention and control. J. Hosp. Infect. 79, 368–370 11 Huang, G. et al. (2007) Virtual patient simulation at US and Canadian medical schools. Acad. Med. 82, 446–451 12 Southwick, F. et al. (2010) IDSA guidelines for improving the teaching of preclinical medical microbiology and infectious diseases. Acad. Med. 85, 19–22 13 Thakore, H. and McMahon, T. (2006) Virtually there: e-learning in medical education. Clin. Teach. 3, 225–228 14 Huwendiek, S. et al. (2009) Design principles for virtual patients: a focus group study among students. Med. Educ. 43, 580–588 15 Bowen, J. (2006) Educational strategies to promote clinical diagnostic reasoning. N. Engl. J. Med. 355, 2217–2225 0966-842X/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tim.2013.10.002 Trends in Microbiology, December 2013, Vol. 21, No. 12
615
Developing virtual patients for medical microbiology education David McCarthy1, Ciaran O’Gorman2, and Gerry J. Gormley3 1
46 White Glen, Derriaghy, Lisburn BT17 0XN, UK Centre of Medical Education, Queen’s University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast BT9 7BL, UK 3 Department of General Practice, Queen’s University Belfast, Dunluce Health Centre, 1 Dunluce Avenue, Belfast BT9 7HR, UK 2
The landscape of medical education is changing as students embrace the accessibility and interactivity of e-learning. Virtual patients are e-learning resources that may be used to advance microbiology education. Although the development of virtual patients has been widely considered, here we aim to provide a coherent approach for clinical educators. For medical education to be effective, both what we teach but how we teach it need to be informed and evidencebased. The delivery of microbiology curricula has been subject to criticism from students who feel overwhelmed by the abstract principles and microbial nomenclature being delivered using traditional lecture formats [1]. Student dissatisfaction with the teaching of microbiology and subsequent resentment towards the subject have been posited as a reason for superficial, assessment-driven learning as opposed to the development of a deeper appreciation and understanding of its relevance to clinical practice [2]. This failure of medical practitioners to engage fully in learning microbiology has consequences for patient care. It has been suggested that both medical students and doctors exhibit suboptimal application of microbiological principles in practice, such as adherence to hand hygiene procedures [3]. There is often a disconnect between what students are taught and how they apply this knowledge. Narrowing this theory–practice gap is a key objective for modern medical microbiology curricula. Therefore, it is vital to scrutinise how microbiology curricula are delivered. Are they accessible and relevant to students and are there any educational resources that could help improve student application of microbiological principles in practice? Learner and teacher acceptance in using e-learning resources has developed greatly. There is a developing trend whereby students appreciate the role of e-resources in complementing or even replacing other learning materials [4]. Despite the inherent difficulties in comparing e-learning resources with non-computer modalities [5], evidence is emerging that integration of e-learning Corresponding author: O’Gorman, C. ([email protected]). Keywords: virtual patients; e-learning; education; microbiology.
resources into microbiology education may improve examination scores compared to the use of traditional lecture formats [6]. Virtual patients (VPs) are one element in an expanding portfolio of e-learning resources. VPs are considered to be computer programmes that endeavour to replicate a safe clinical experience in which the student can assume a doctor-in-charge role while being guided through a clinical expert interpretation of the presentation, diagnosis, and treatment of key medical conditions [7]. VPs have pedagogic value in that they reactivate prior knowledge gained from earlier teaching (vertical integration) or other concurrent sources (horizontal integration), making it accessible as working memory to generate new knowledge. This reactivation and subsequent generation of knowledge can result in VPs being more effective facilitators of both shortand long-term memory retention when compared with traditional methods of teaching such as lectures and small group work [8]. VPs provide a secure educational environment in which students can learn from their mistakes before engaging with actual patients. This safe and forgiving space has been shown to result in students feeling more prepared for human interactions [4]. VPs can deliver a wider range of scenarios than may be encountered during bedside teaching, can readily link answers to the contemporary evidence base, and are cost-effective [9]. VPs complement a widely dispersed student population because they allow the study of materials regardless of student location, teaching staff availability, and patient accessibility [9].This has led to academic evaluation of repurposing of VPs, whereby these resources are shared on an inter-institutional and/or interdisciplinary basis to further improve their cost effectiveness. VPs also have unique potential in the development of clinical reasoning skills. Clinical reasoning involves acquiring, analysing, and integrating clinical information from various sources (e.g., patient history, examination findings, laboratory results and radiological investigations) into a diagnostic management plan. This does not equate to understanding the basic scientific principles involved in performing a skill (which can be taught via lectures, small groups, or computer-aided instruction) or the ability to perform it correctly (which can be taught using standardised patients or simulators in a clinical skills centre.) In the context of medical microbiology, clinical reasoning relates to appreciating when to perform a 613
Forum: Science & Society
Trends in Microbiology December 2013, Vol. 21, No. 12
clinical test and how to interpret the results meaningfully [5]. Clinical reasoning in expert practice becomes a nonanalytical and unconscious process of recognising patterns of presentation. The benefit of using VPs is that they can act as longitudinal case simulations that can reflect several doctor–patient interactions, and therefore provide a template for pattern recognition in future clinical encounters. In medical education there is emerging interest in blending simulation (including VPs) into curricula and evaluating the benefits of doing so. The literature shows a positive correlation between VP integration into medical curricula and student application of clinical skills in specialties such as haematology and cardiology [5,8]. However, despite research suggesting that e-learning resources can foster a positive attitude towards microbiology education [10], there is evidence that medical schools that developed VPs are reluctant to include a microbiology or immunology component [11]. Furthermore, there appears to be a paucity of research evaluating the use of these resources in microbiology education. We suggest that the potential for VP integration into microbiology curricula is currently underappreciated and propose that the roles for VPs in medical education support several of the core objectives [12] identified for microbiology and infectious disease curriculum development (Table 1). Although there is limited evidence relating directly to microbiology, the process of VP development more generally has attracted considerable attention. Thakore and McMahon proposed a four step process for VP development [13]: (i) Identify the educational objectives; (ii) Design the content; (iii) Build or create the multimedia materials relevant to the educational objective; and (iv) Integrate and evaluate the e-learning resource within the curriculum. To meet our educational objectives, we developed content related to common or catastrophic diseases, providing students with a spectrum of frequently encountered conditions while recognising the necessity of exposure to lifethreatening infections. The process of designing content and creating the supporting media has been considered by other authors [14,15]. With the modelling of clinical reasoning and the promotion of student satisfaction as our aims, we identified eight design features that were used to develop our microbiology VP suite for medical students in Queen’s University Belfast (Figure 1). Ethical approval was obtained from the School of Medicine, Dentistry and Biomedical Sciences Ethics Committee of Queen’s University Belfast. The VPs were developed for
Use content relevant to student's clinical experience Provide 'Doctor in Charge' experience
Use media student may encounter on ward
Blend of open quesons and mulple choice quesons
VP design features
Provide immediate feedback to answers
Probe for differenal diagnosis as case progresses
Ask for discriminang features of key condions
Describe probability and priorisaon of condions
TRENDS in Microbiology
Figure 1. Key design features for virtual patient (VP) design.
third-year medical students studying at Queen’s University Belfast, where an integrated spiralling curriculum has been adopted. The resource was distributed to all 278 students as distance learning materials to provide a curriculum-enhancing learning experience. In designing and creating the multimedia material, we integrated images, audio recordings, and videos to faithfully replicate the results of various investigations and examinations alongside commonly encountered hospital charts. In all instances, the relative importance of the media was emphasised through immediate feedback that related back to the presentation, differential diagnosis, and treatment to help inform the decision-making process. Video S1 in the supplementary material online shows how we integrated these features into a microbiology VP resource. Our overall intent was for students to simulate autonomous clinical practice, modelling the doctor-in-charge role. Video S1 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.tim.2013.10.002. In conclusion, microbiology VPs are an underappreciated tool in the medical educator’s toolbox. In today’s world, the majority of medical students can and do access e-resources from a range of devices. Whether in the classroom, at home, or on the ward, VPs allow students to interact with clinically relevant content that is challenging, informative, and
Table 1. How VPs can help deliver the objectives of microbiology medical education Objective Review course material
Familiarise students with differential diagnosis Show the relevance of basic science
614
Desired outcomes Understand how viruses, bacteria, and fungi cause disease Know the names and virulence strategies of the major clinical pathogens Know which pathogens infect which specific organ systems Generate a differential diagnosis Be familiar with the diagnostic approaches to infectious diseases Integrate facts related to microbiology and infectious disease and apply them to specific patients Choose an appropriate anti-infective therapy
Forum: Science & Society consistent. From a resource perspective, VPs are a costeffective reproducible e-learning resource that can model the fundamentals of clinical experience while fostering student confidence in a safe learning space. We believe that VPs are tools that encourage both clinical reasoning and student satisfaction and thus are closely aligned to our needs as educators of infection medicine. References 1 Beylefeld, A. and Struwig, M. (2007) A gaming approach to learning medical microbiology. Med. Teach. 29, 933–940 2 Osborne, J. et al. (2003) Attitudes towards science: a review of the literature and its implications. Int. J. Sci. Educ. 22, 1049–1079 3 O’Brien, D. et al. (2009) Survey of teaching/learning of healthcareassociated infections in UK and Irish medical schools. J. Hosp. Infect. 73, 171–175 4 Balasubramaniam, C. et al. (2009) Repurposing existing virtual patients: an Anglo–German case study. Bioalgorithms Med. Syst. 5, 91–98 5 Cook, D. and Triola, M. (2009) Virtual patients: a critical literature review and proposed next steps. Med. Educ. 43, 303–311 6 Desai, N. et al. (2000) Infection control training: evaluation of a computer-assisted learning package. J. Hosp. Infect. 44, 193–199
Trends in Microbiology December 2013, Vol. 21, No. 12 7 Association of American Medical Colleges (2007) Effective Use of Educational Technology in Medical Education: Summary Report of the 2006 AAMC Colloquium on Educational Technology, Association of American Medical Colleges 8 Botezatu, M. et al. (2010) Virtual patient simulation: knowledge gain or knowledge loss. Med. Educ. 32, 562–568 9 Boye, S. et al. (2012) An e-learning course in medical immunology: does it improve learning outcome? Med. Teach. 34, e649–e653 10 O’Neill, E. et al. (2011) Use of e-learning to enhance medical students’ understanding and knowledge of healthcare-associated infection prevention and control. J. Hosp. Infect. 79, 368–370 11 Huang, G. et al. (2007) Virtual patient simulation at US and Canadian medical schools. Acad. Med. 82, 446–451 12 Southwick, F. et al. (2010) IDSA guidelines for improving the teaching of preclinical medical microbiology and infectious diseases. Acad. Med. 85, 19–22 13 Thakore, H. and McMahon, T. (2006) Virtually there: e-learning in medical education. Clin. Teach. 3, 225–228 14 Huwendiek, S. et al. (2009) Design principles for virtual patients: a focus group study among students. Med. Educ. 43, 580–588 15 Bowen, J. (2006) Educational strategies to promote clinical diagnostic reasoning. N. Engl. J. Med. 355, 2217–2225 0966-842X/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.tim.2013.10.002 Trends in Microbiology, December 2013, Vol. 21, No. 12
615
