Hands-on learning through simulation is a cornerstone in the 21st-century curricula of US healthcare professional schools. Standardized patients (individuals specially trained to portray patients), volunteers, and manikins act as patients during simulated patient encounters. Simulations enable students to gain clinical proficiency by applying classroom and book knowledge to lifelike near-real clinical scenarios. Because these simulations put classroom learning into action, they’re incredibly beneficial to students building clinical knowledge and skills, including interpersonal and communication ability.

Schools like Rosalind Franklin University of Medicine and Science (RFUMS) view simulation as an essential way for students to develop communication, psychomotor, and diagnostic-reasoning competencies. Rosalind Franklin’s more than 2,100 medical (MD), physician assistant (PA), physical therapy (PT), nurse anesthesia, podiatry, psychology, and pharmacy students use simulated patient encounters to bridge classroom learning with clinical practice and gain diagnostic proficiency before they work with real patients.

But there are tradeoffs: While traditional manikin and standardized-patient-based simulations offer quality student-learning experiences, they’re often labor intensive for healthcare professional schools to coordinate, can be costly to organize, and as a result, happen less frequently than needed to help learners progress to mastery. Educators at RFUMS understand the value of simulation in health-professions education, but, as with many other schools, logistical considerations impact how often face-to-face simulations can occur.

Beyond the cost and logistics to implement various types of simulation, there are other limitations to note as well. Manikin-based simulation puts students in charge of many aspects of patient care, but the subtleties of human interaction and bedside manner can be difficult to replicate on a manikin. Likewise, standardized patients can authentically portray a case history and many physical exam maneuvers, but are unable to replicate the clinical findings associated with many conditions (abnormal heart and lung sounds, altered vital signs, etc.). These limitations can pose a threat to engaging learners in a simulation that authentically engages the breadth and scope of the complexities in diagnostic reasoning.

In an effort to overcome some of the limitations of manikin and standardized patient-based simulations, RFUMS has included the use of virtual patients as a complement to more traditional forms of simulation. Through tailored virtual-case studies, RFUMS is helping students master clinical competencies, diagnostic reasoning, and the clinician-patient encounter through a hybrid approach to simulation-based training.

A hybrid approach to simulation

RFUMS found that virtual patients can serve to increase the use of simulation in health-professions curriculum and provide a simulation-based modality that can compensate for limitations noted in other forms of simulation. In 2011, RFUMS integrated the i-Human Patients virtual-patient platform into its curricula. Using this platform, students interview a virtual patient about symptoms and medical history, perform a physical exam, develop differential diagnoses (hypotheses about potential diagnoses), order appropriate tests, confirm the diagnosis, and develop a treatment plan. Professors see exactly what questions students posed, what exams they performed, what tests they ordered, and review how well the student performed in each section. By reviewing the student’s information, professors provide feedback and constructive critiques that help students learn from their successes and mistakes. Students at RFUMS now supplement their traditional learning with online case studies and virtual simulation in order to sharpen their diagnostic- and clinical-reasoning competencies while applying their knowledge to cases that mimic real-life patients.

Diagnostic-reasoning proficiency is a core competency for many students at RFUMS, and virtual patient simulation provides a method to effectively teach this critical skill set, according to Jim Carlson, the dean of the college of health professions and associate vice-president for clinical simulation at RFUMS. Professors conduct virtual-patient case simulations in the classroom, and in many cases, using a flipped classroom model, students are assigned a case to complete before a class. The simulation acts as a jumping-off point for classroom discussion and more in-depth analysis and learning.

One method used at RFUMS is a hybrid simulation. For example, students first work through a case on the virtual platform focused on the cognitive skill of establishing a diagnosis, and then may transition to the manikin lab (Figure 1) to test their procedure skills such as removing fluid from the lungs or inserting a breathing tube as a corrective measure for the case presentation. After performing the procedure, students return to the virtual patient, input their findings, and continue monitoring the patient.

Figure 1:
Students can test their procedure skills in the manikin lab

“Virtual patient simulation allows us to provide greater variation and realism in the classroom,” Carlson said. “Now we can examine the patient in the classroom, and students have to use their diagnostic reasoning skills to figure out the problem rather than being told how to solve the problem. Virtual-patient simulation has shifted my instruction away from telling students what they should be considering toward an emphasis on honing their own skills and thinking through problems. It adds a layer of depth and realism to what we can bring to the classroom, since virtual patient encounters mirror what students will see in the clinical environment.”

Training students in tough-to-teach areas

RFUMS also found that virtual patient encounters address many areas of training for which student exposure is traditionally difficult. Take, for example, geriatric and pediatric care. Infants, toddlers, and senior citizens are infrequently cast as the standardized patients that act out ailments. As a result, students rarely conduct live simulations on real patients in these age groups. Additionally, it is difficult for students to acquire an adequate volume of actual patient experiences in these vulnerable populations. The use of virtual-patient cases focused on these hard-to-reach demographics allows RFUMS students the opportunity to acquire experience that is essential to future practice, but hard to achieve through traditional learning formats. (Figure 2)

Figure 2:
Virtual patient cases (i-Human) allow students the opportunity to acquire essential experience

Obstetrics is another area of medicine that is difficult to teach through actual patient interaction. Clinical rotations are much shorter than nine months, so medical students don’t see one patient through the entire cycle of a pregnancy. Finding a pregnant woman willing to be a standardized patient in a live simulation is also difficult, so students tend to have very little hands-on experience managing a patient through the duration of her pregnancy.

Virtual patient encounters have helped closed this gap, offering new opportunities to manage obstetrics and pregnancy-related cases, Carlson said. At RFUMS, students interact with virtual avatars who can model patients at various points during pregnancy with differing complications. When applicable, students can participate in the delivery of the baby through the birthing simulator in the manikin lab.

Experience needed—students get it

At RFUMS, students sharpen their diagnostic reasoning competencies through scores of virtual cases during their education, serving as a complement to face-to-face simulations and actual patient experiences. Professors have a new way to keep students engaged and active in their learning, especially in the first two years of MD school or first year of PA school where clinical exposure is limited.

Or, as Carlson explained, virtual simulation gives RFUMS students the ability to test a hypothesis without threatening patient safety. Still, these simulations hold students accountable for their decisions, and the software can pinpoint mistakes to provide feedback in meaningful learning, Carlson said.

Because of the availability of these simulations—accessible anytime and anywhere there’s an Internet connection—students now have the ability to constantly test and refine their diagnostic competencies. In turn, they grow more adept at diagnosis and management both before working with actual patients and as they continue to develop the clinical ability.

Many graduates of the school’s MD and PA programs have cited their virtual simulation experiences at RFUMS as beneficial to their early interactions with patients. According to Carlson, this training has helped students develop their competencies in pre-clinical training, and refine their diagnostic proficiencies and clinical reasoning before participating in the care of actual patients.

The future of medicine and simulation

Acquiring clinical competency is complex and time intensive. Manikin and standardized patient simulations have established themselves as a core part of healthcare education. But these simulations can be time consuming and difficult to coordinate, and they don’t always cover the full gamut of patient-care experiences needed to provide doctors and PAs with a well-rounded education.

Virtual patient simulations, now being used in US healthcare professional schools like RFUMS, can better shape the diagnostic and critical thinking skills of students than other forms of learning. These simulations can be used in classrooms to provide another layer of learning as independent homework, as a standalone group-learning tool, or as a complement to other forms of simulation. Now and in the future, students will gain valuable experience by working through virtual cases and simulations, as they develop diagnostic reasoning and hone clinical-care skills to ensure the best patient outcomes.