A few million people around the world and thousands in Israel have gone through medical school in recent decades and become MDs, but the ways in which they are taught and tested before graduation and for specialization are far from being optimal.Clinical medical education is based on a combination of frontal lectures, reading medical literature and bedside teaching, accompanying senior doctors on their clinical rotations among hospital patients. While interacting with patients is obviously the most important part of medical education, it has practical limitations as it requires a large group of experienced and well-trained instructors and is time consuming, and also because there are not enough patients with an adequate spectrum of diseases.Similarly, medical exams based on real patients have been shown to have low reliability, as one evaluator subjectively passes a student while another fails him (or, increasingly, her) for the same interaction.
Therefore, all medical schools have added to the evaluation of students the multiple choice (“American”) exams. These exams evaluate mainly knowledge, but their ability to assess clinical competence is limited.Many schools have replaced the bedside testing with an “objective structured clinical examination” (OSCE), simulations by a series of actors who play the roles of patients.But to be effective, the actors must do this on a regular basis, rather than a few times a year, and in any case, their bodies cannot show real signs of disease beyond limbs tinted with red makeup or simulating pain by yelling “Ow!” when a student touches his toe. OSCE enables evaluation of doctor-patient interaction, but it does not include further evaluation and treatment. It is also very expensive: only few medical schools can afford using actors for exams, and even less can use them as a teaching tool.SO HOW can medical schools do better educating future MDs from the anamnesis (taking a patient’s multifaceted case history) through laboratory evaluation and imaging to treatment and assessing recovery? Prof. Arie Oliven, former chief of internal medicine at the Rappaport Faculty of Medicine of Haifa’s Technion-Israel Institute of Technology and recently retired after a quarter-century as head of Internal Medicine B at Bnai Zion Medical Center (but still conducts research and teaches there), has grappled with this quandary for the past decade.The internist and pulmonologist “saw a problem in how we teach and assess medical students. When there is a small team assessing students, it is not very objective.But multiple-choice exams don’t cover everything they should know,” continued Oliven in an extensive interview with The Jerusalem Post. “So I initiated a computerized database of clinical cases in internal medicine in which the student ‘interviews’ simulated patients, typing questions into the PC and interacting with it to reach a diagnosis and treatment plan. The Virtual Patient is an Internet-based application that can be used for learning at home for practice as well as for testing in the faculty. I am still very much involved in the system’s design today.”Oliven linked up with veteran computer and information technology experts Dr.Adam Baruch and Daniel Fatelevich and established Virtual Patient (VP) Ltd., a company in Kiryat Haim near Haifa that a year ago began to commercialize the platform.“There are other virtual patient programs out there,” said Oliven, “but they are either limited to specific technical tasks, or have multiple limitations. When the term is typed into Google, our system comes up first. Our students sitting at the computer screen are presented with case study after case study, created by medical professors in a specific field.”The platform has a total of 230 separate patient case studies to choose from.For example, a 60-year-old patient complains of headache; his blood pressure and other vital signs are presented on the screen. Within some 20 to 40 minutes, the student types in verbal questions to reach a differential diagnosis and rule irrelevant conditions out. It’s like talking to a real patient (in Hebrew, although some of the material has already been translated into English). It can be expanded to orthopedics, pediatrics, gynecology and other specialties as soon as experts in these fields join the project and prepare clinical cases for the databases. “In theory,” he continued, “it can be translated into any language and include almost all fields of medicine, as well as many para-medical professions.”The student conducts an open dialogue with the computer, writing medically relevant questions in free wording, and the system “understands” the question and replies a pre-programmed reply. The ability to conduct a free dialogue is based on natural language processing, with a lexicon of keywords.A major shortcoming of competing systems, Oliven explained, “is the difficulty in preparing new cases, particularly when natural language recognition is used. To facilitate this task, complex visual modalities were avoided and multiple mechanisms were introduced by the computer experts to enable simple creation of new cases, particularly when a basic prototype of a specific complaint or finding was already made.”Before implementation into the teaching and exam curriculum, common clinical symptoms like chest pain, anemia and so on – with several case scenarios for each were prepared (for example, for chronic diarrhea, Crohn’s disease or celiac disease). The student must narrow down the differential diagnosis by his dialogue with the computer, asking for specific items of physical examination, ordering laboratory tests and imaging and evaluating their results and other evidence. Laboratory and imaging tests as well as drugs and other treatment modalities are taken from extensive lists similar to those used in hospitals and the health funds.In addition, a “learning modality” for the VP was created to add words and items asked by the students, that the system did not yet recognize.It’s like “a flight simulator for doctors,” said Oliven. “Some conservative doctors may think you have to teach and test students only at the bedside and not in front of a computer screen. But I must stress that the system doesn’t come instead of the bedside. A major use is for practicing at home, and students will not spend less time speaking to and examining actual patients.”In addition, the computerized exam in our faculty was always just a small portion of the comprehensive evaluation of the students.The Israeli virtual patient program is also the only one in which students can type open questions that the computer answers, said the Haifa professor. The PC screen shows symptoms, like spots on the skin or swollen lymph glands, as well as the results of x-rays and sophisticated scans, and it allows the student to order specific lab tests and assess their results.Among the advantages, said Oliven, are VP’s cost effectiveness, unique user interface, objectivity and reliability, accessibility to anyone with Internet access, immediate results and flexibility as potentially multilingual and multidisciplinary.To pass the exam, the student needs to practice the management of multiple cases on the exercise system, that is identical to the exam’s system, but also provides feed-back and explanations. This practice, often not encountered during the limited stay of students in the hospital, is in reality the primary goal. Therefore, combining the practice and exam system is one of the main advantages of this virtual patient. The number of tests the student can order is limited so they learn to narrow them down and not waste precious health system resources.“You can also hear sounds of the heartbeat, respiration, digestion and coughing that we recorded and put it into the computer database. The student can view the relevant electrocardiogram results.”You can use as many simulated patients and medical conditions as you need, Oliven said. “The student has to know what he or she has to look for. If they don’t know, they won’t find the answer. you don’t know, you wont find it.” Also, ordering wrong invasive examinations or inadequate drugs (including forgetting to ask about allergies) lowers the final grade. The students should learn from their early beginning of clinical studies the importance of patient safety – primum non nocere (“first, cause no harm”).TODAY’S AVERAGE medical student gets his diploma “without once taking a patient from the beginning with his symptoms and processing the case through all the stages ending with treatment and follow-up.Except for the Rappaport School in Haifa, no medical faculty does this. We have for several years been preparing and testing our students on this with the platform and written our findings up in medical journals here and abroad,” said Oliven.A number of years ago, older doctors steered clear of laptops. But today, everybody uses smartphones and tablets and feels comfortable with them – even a pensioner like me.”Another advantage of VP, whose Web 2.0 interactive software application is designed to provide a complete e-learning and e-assessment environment for any medical school, is that one can press a button after the student is tested and see his grade immediately. “But we don’t do this yet, because we want first to ensure the reliability of all questions.”His son, who in the pervious decade studied medicine at the Technion, was one of the first to try out the platform. “We carried out an integrated test with some cases with actors and compared the results with VP. Our system was objectively found over several years to be more accurate for testing medical skills and knowledge than the actors,” recalled Oliven. “Many medical schools here do not have large computer rooms as we do. We can accommodate half a medical school class at a time in our own facility.”THE VP system was developed in full cooperation with the Technion medical faculty, and the company and the university entered a business partnership to further develop and promote it as it serves as the standard learning and testing facility of Rappaport’s internal medicine department. Dr. Rachel Nave, the Rappaport faculty’s coordinator of testing and medical education, is very familiar with and enthusiastic about the VP platform and hopes the fields in medicine that it teaches and tests will be expanded quickly as more specialists hear about it and are ready to supply the clinical cases.Baruch, VP’s senior computer expert and co-founder, noted that the various other medical faculties have been given information about the VP system and are showing interest in using it, with some already negotiating for purchase. The company has also heard from medical schools as far away as China, said Baruch, who earned his doctorate in computer sciences and taught at the prestigious Massachusetts Institute of Technology. Asked about the cost he was noncommittal, saying it depends on the medical school and the number of students who would use it.“But it is clearly the wave of the future and will be a revolution in medical teaching. We want to turn it into the gold standard.”Baruch suggested that VP can be used not only for medical school students and teaching medical specialties but also for nursing schools and training paramedics, nurse practitioners and physician assistants.
Virtual Patient 2015