Learning from a textbook can only take you so far, and when doctors need to put theory into practice in a safe environment, they often turn to patient simulations that use a case study approach to emulate real life clinical scenarios.
Modern day recognisable simulations have been used in medical education since the 18th century and have evolved into realistic and medically accurate physical and digital solutions designed to allow learners to simulate a scenario-based encounter with a patient in a safe environment.
This has ultimately led to the development of virtual patient simulations (VPS), which have become one of the most impactful ways clinicians can learn.
Virtual patient simulations take place online and aim to be goal-orientated, case-based, and rule-based, encouraging learning through active decision making and developing competencies that can be applied in real-world practice.
Often, this will involve virtual patient avatars that realistically respond to treatments. Physicians may be able to take a reading from a virtual blood metre and listen to an MP3 recording of a real heartbeat to determine a diagnosis for a specific case study.
The technology is also now evolving to include things like virtual reality (VR) and natural language processing (NLP) to make these interactions even more life-like.
“We often equivalate virtual patient simulations to flight simulations when first introducing the concept to people,” explains Martin Warters, Medscape’s director of learner experience, “although that’s not a completely accurate definition, as patient simulations take more of a cognitive behavioural approach to learning, focusing on application of knowledge and behaviour change, whereas flight simulators are more procedural.
“In virtual patient simulations, learners have the opportunity to interview the patient, to make diagnoses and orchestrate follow-ups. Every single decision they make will be referred back to clinical guidance for immediate feedback on the appropriacy of that decision.
Though patient simulations have been around in one form or another since the Middle Ages, modern simulation can mostly trace its roots back to the 1960s and 70s and the development of standardised patients.
Standardised patients involve an actor playing the role of the patient with a given condition, who can be interviewed by medical students.
With the advent of the internet, though, patient simulations were able to reach “the next level”, says Warters, who worked in teacher training and curriculum design before joining Medscape.
The technology supporting virtual patient simulations is only going to keep evolving – for instance, natural language processing (NLP) techniques based on AI technology could be a game-changer for patient simulations.
NLP allows computers to better understand normal human speech and respond in a realistic way.
“At the moment, physicians have to type in their questions and responses or select them from a list. Now, though, developers are trying to produce a much more natural way of communicating with virtual patients, where the learners can actually speak to them and the software can understand them and give realistic answers.”
Meanwhile, with the Internet of Things and other advances in tech, the industry may be able to get to the stage where virtual patient simulations are used as a direct learning tool in the clinic.
“For example, if you knew you were going to see a patient with diabetes, before they arrived you could generate a virtual patient with the same conditions, the same comorbidities, and the same history to try out different aspects of patient management,” says Warters.
Looking even further into the future, Warters says that volumetric holograms may one day allow patient simulations to hit new heights of realism – perhaps sooner than we think.
“We’ve tentatively started exploring that technology – it would be really cool if we were able to put a 3D patient in front of the learner, so that they can perform all the same tests they would use in a clinical setting. It sounds incredible to even be saying that, but that’s certainly one way we see the technology evolving.”
Until then, technologies that are more within reach, like virtual reality (VR), are starting to show their potential in making simulations even more immersive.
“VR in patient simulations is mostly in the proof of concept stage right now,” says Warters, “but it could be a great vehicle for virtual patient simulations. For example, we recently created a really compelling programme about an Alzheimer’s patient, where you could see the same event from four separate viewpoints – the patient, the doctor, the patient’s caregiver, and the patient’s son – through the VR headset, and we worked in a narrative about the different dynamics going on.”
Warters stresses the importance of keeping up to date with the latest technology developments to see if they can be applied to patient simulations – and that includes not just monitoring the medical education sector, but also entertainment industries like film to see how they are using the same tech.
“These technologies have limitless applications, but they’re also so new that everyone is still figuring out how to best harness them.”
Ultimately, though, Warters says that a blended approach is likely to dominate simulations of the future, and there will always be room for different tools in different circumstances.
“In complex, treatment-heavy disease states with comorbidities, techniques such as NLP might not be that applicable, but things like psychiatry lend themselves really nicely to that technology.”
He points out, though, that virtual simulations can already be incredibly realistic – and this will only improve further as technology evolves.
These methodologies have seen as much evolution as technology over the years, and Warters points out that running a good virtual patient simulation is about more than just the digital tools – it’s also about telling a story.
“You need to take really dry clinical facts and turn them into compelling narratives to really help with the learning process.
“Take a patient who is unable to walk four flights of stairs without shortness of breath as an example. You could look at the barriers preventing that patient from receiving the best care – perhaps she is a single mother with small children, from a low socio economic background, and her main concern could be not being able to look after her children. You could ask why she is walking so much – does she live in a fourth-floor apartment, so she has to walk up four flights of stairs every day?
“That turns the case into a humanised patient that is in front of you, who you’re able to treat in a more immersive environment. That’s key to the success of a virtual patient.”
Medscape also listens to HCPs to find out what they want to see from a good virtual simulation programme.
“They tell us that they like to see more of a continuum of care, and simulations that take them through different stages of a disease state,” says Warters. “In real life, they might see a patient one week who has shortness of breath and put it down to seasonal allergies, but then they come back two weeks later to say it has progressed. That’s the kind of progression we want to emulate more often.”
Warters adds that it’s also important to ensure the learning environment is “psychologically safe” for HCPs.
“For a lot of people, the idea of making mistakes and causing harm in a real-life human is mortifying. It’s important to set up a learning environment that both reflects real-life practice but is also safe.
“If you make mistakes, no one’s going to get sued – there are no virtual lawyers with virtual lawsuits looking at malpractice cases. Physicians have free reign to make as many mistakes as they want, with the ultimate goal of learning from them.
“That also encourages experimentation. Doctors might have types of patients that they see every week, where they have a pre-determined idea of how best to treat them. With a safe virtual patient platform, they have the opportunity to try out new things, whether that be a new treatment, a new algorithm, or a new testing protocol.”
Ultimately, the combination of evolving technologies and improved methodologies will work towards better patient outcomes.
“A third of all medical knowledge is outdated every five years, and then every 15 years the body of knowledge doubles,” says Warters. “If you consider the fact that the average working career of a doctor in the US is 36 years, that’s a lot of new insights and new innovations for them to take in over the course of their life.
“We’ve got doctors coming towards the end of their career who went into practice when AIDS/HIV was first becoming a recognised disease, and were literally learning in the field with the patients who were coming in. They needed continuous education and patient simulations to manage that.
“On the other hand, there are going to be so many health challenges that the world will see in the future, and students coming into the field right now are going to need education on them.”
Warters says that COVID-19 is a prime example of this.
“The virtual patient is a great way to disseminate the current best-practice knowledge of a disease state and allow the learner to apply this new knowledge in a risk-free, frictionless environment, so they can learn from what they’re doing, see what mistakes they could potentially make and discover the benefits, pros and cons of each treatment – with the ultimate goal of getting this knowledge into the patient population.”
Martin Warters is the director of learner experience at Medscape. He has over 15 years’ experience creating simulations, having worked previously in the fields of Aviation and the Energy Industry. For the last nine years he has been working in the realm of Virtual Patient Simulation, spearheading the design of MedSims. Martin has a background in Educational Technology, Serious Games, and XR. His role at Medscape is dedicated to the development and advocacy of innovations and solutions within the field of emerging and immersive technologies for healthcare professional education. Martin’s area of expertise is in the educational design and theory in the design of Virtual Patients.
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George Underwood is a senior member of the pharmaphorum editorial team, having previously worked at PharmaTimes and prior to this at Pharmafocus. He is a trained journalist, with a degree from Bournemouth University and current specialisms that include R&D, digital and M&A.