Lena Sjöberg-Tuominen & Kalle Romanov
In the medical curriculum, various teaching methods are commonly com-bined to train students to adopt clinical skills, perform diagnostic reason-ing and select the correct treatment of the patients. The teachreason-ing has traditionally involved various modalities such as lectures, clinical rounds, and small group sessions. Unfortunately, these campus-oriented modali-ties are often insufficient in mediating the basic skills students need to enable them to manage the clinical process in the care of primary care patients. Additionally, the symptoms and complaints encountered in pri-mary health care are rarely seen in the setting of a university hospital inpatient or outpatient clinic. On the other hand, neither the students nor their teachers have regarded paper-based patient cases as a dynamic and stimulating learning method.
To improve teaching methods, educators have developed interactive computerized sessions that would enhance student activity and provide them the opportunity to practice their skills. Such methods could effective-ly train students to master the knowledge and skills needed to run a suc-cessful primary care practice. The use of virtual patients in medical teach-ing has increasteach-ingly been adopted in medical schools (Huang 2007).
The web-based virtual patient pool, VPP, was developed in the medical faculty of the University of Helsinki during the VPP project in 2004-2006.
The goal was to develop web-based software to simulate the natural process of clinical examination of adult patients, and VPP was designed to allow students to perform extensive clinical examinations and investiga-tions on virtual patients.
Each virtual patient is associated with up to four stages or activity types, denoted by the terms history, examination, investigation, and manage-ment. History is the activity directed at asking the patient questions. Ex-amination is the physical exEx-amination of the patient. Investigation
104 represents the use of available laboratory, radiological and other services provided. The VPP enables students to record a complete medical history of the patient, perform a clinical examination, including auscultation of the heart and lungs, to take all necessary laboratory tests, examine the pa-tient with medical imaging methods, and examine the papa-tient with diag-nostic procedures. For each patient, the student may choose from none to many items within each stage, although most patients will tend to follow a sequential pattern of history, examination, and investigation. There is no requirement to undertake any of these, and they can be undertaken in any order.
Lastly, the management of the patient (i.e., diagnostics and treatment) covers those issues that are the central outcomes of the whole process.
Diagnostics covers the student's attempt to identify precisely the nature of the patient's health problem. The treatment aims to modify the outcome for the patient, for example through treatment with medication or perhaps physical therapies. The criteria for a completed virtual patient may include just the diagnostic process or students may also be required to formulate a treatment plan for the patient.
As an example of the process, the student might begin by asking the pa-tient, “What brings you here today?” Further questioning would also be directed at assessing how the underlying condition had been managed to date and whether some other process might be affecting the current health status of the patient. Once the patient’s history has been ascer-tained, the student begins the physical examination with an initial evalua-tion of the patient’s vital signs, including pulse and blood pressure. The student might then inspect the general status of the patients. The clinical examination is directed at identifying objective indications of illness. Hav-ing completed a relevant physical examination, the student would order laboratory and other investigations in order to confirm (or exclude) the anticipated diagnosis and to assess the consequences of the underlying condition.
105 Picture 1. The virtual patient is examined: by clicking on his body, inserted photographs of genuine findings appear.
At any point, the student has the opportunity to return to another stage, such as the recording of the patient’s history, verifying whether items have been overlooked or an unexpected finding was found in the examination, or as the result of investigations.
The teacher can design the properties of a VPP virtual patient in order to emphasize certain student activities and actions assigned relevant to the diagnosis or management of the patient. This same relevance can also be assigned to selected laboratory investigations and medical imaging.
After finishing the whole process with a virtual patient, the student can compare immediate feedback on his/her performance against a golden standard defined by the teacher. This feedback contains a list of relevant issues to be covered in recording the patient’s history, physical examina-tion, ordering investigations, and choosing a management.
For the teacher, the VPP will produce detailed information on how each individual student is performing with a virtual patient. In addition, summa-rizing statistics displaying the average performance of all students are available for the teacher.
106 In earlier studies, we have investigated how students utilize voluntary VPs and discovered that the use was associated with better outcomes in a semi-annual progress test. VPs are more often voluntarily utilized by stu-dents who already perform better in clinical topics (Kuusi and Romanov 2008). Therefore, this type of teaching should be integrated into clinical studies in order to reach those students who need it more.