learning clinical reasoning in virtual environments

INSTITUT FÜR DIDAKTIK UND AUSBILDUNGSFORSCHUNG IN DER MEDIZIN

LEARNING CLINICAL REASONING IN VIRTUAL ENVIRONMENTS Hege I, Kononowicz AA, Adler M, Kiesewetter J. MEFANET, Brno 2017

Images of this slide are available under a Creative-Commons-license http://www.flickr.com/photos/59939034@N02/

Effective Clinical Reasoning in Virtual Patients (VPs)

§  Funding: Horizon 2020 Marie-Curie Global Fellowship §  Duration: July 2015 – Dec 2017 (first 1.5 years at Dartmouth) §  Project aim: Research, develop, and evaluate a tool and guidelines to enhance clinical reasoning training with virtual patients.

§  Project Partners: §  Ludwig-Maximilians-Universität München, Germany §  Geisel School of Medicine at Dartmouth, Hanover, USA §  Instruct AG, München, Germany

KLINIKUM DER UNIVERSITÄT MÜNCHEN® 2

www.virtualpatients.net


Clinical reasoning

§  Different models, descriptions, synonyms..... §  > 2300 hits in PubMed since 1956 §  Changes over time §  Unconscious, non-linear elements §  Accross healthcare disciplines (Norman G. 2005)

Eva K (2004). What every teacher needs to know about clinical reasoning. Med Educ 2004; 39:98-106

Bonilauri Ferreira APR, Ferreira RF, Rajgor D, ShahBowen J, Menezes A, Pietrobon R. Clinical J. Educational Strategies to Promote Reasoning the Real World Is Mediated ClinicalinDiagnostic Reasoning. N EnglbyJ Med Bounded Rationality: Implications for 2006;355:2217-25 Diagnostic Clinical Practice Guidelines. Fretheim A, ed. PLoS ONE. 2010;5(4):e10265. doi:10.1371/journal.pone.0010265.

KLINIKUM DER UNIVERSITÄT MÜNCHEN®

Charlin B, Lubarsky Barrows HS, Pickell GC. Developing Clinical ProblemSolving Skills. S, Millette B, Crevier F, Audétat M-C, Charbonneau A, et al. 3 INSTITUT FÜR DIDAKTIK UND through graphical Clinical reasoning unravelling complexity Norton Medical Books, W.W. Norton & Company, NY, London 1991,processes: AUSBILDUNGSFORSCHUNG IN DER MEDIZIN representation. Med Educ. 2012;46(5):454-63. ISBN 0-393-71010-6

Virtual Patients

KLINIKUM DER UNIVERSITÄT MÜNCHEN® 4 INSTITUT FÜR DIDAKTIK UND Kononowicz AA, Zary N, Edelbring S, Corral J, Hege I. Virtual patients - what are we talking about? A framework to classify the AUSBILDUNGSFORSCHUNG IN DER MEDIZIN meanings of the term in healthcare education. BMC Med Educ. 2015;15(1).

Interactive web-based patient scenarios

§  Patient encounter (history -> therapy) §  Learner is in the actor's role §  Suitable to teach clinical reasoning skills §  Why? How?



How is clinical reasoning taught?

§  Clinical reasoning curriculum? Train the trainer? §  Many different methods to teach and assess clinical reasoning skills §  Script Concordance Testing §  Post-Encounter Form §  Summary statements §  ... §  "Assimilation" §  During §  Bedside Teaching §  Internships §  Seminars, PBL-tutorials, lectures §  Virtual patients §  ... §  Often heterogenous and subject specific... (Except for familiy medicine) KLINIKUM DER UNIVERSITÄT MÜNCHEN® 6


Clinical Reasoning in VPs

§  Tasks: Identify & prioritize problems, differentials, §  § 

final diagnosis Formats: Multiple Choice, lists, decision points,.... Usually quantitative feedback/scoring

http://player.casus.net

Image taken from Stathakarou N, Zary N, Kononowicz AA. Beyond xMOOCs in healthcare education: study of the feasibility in integrating virtual patient systems and MOOC platforms. PeerJ. 2014 13;2:e672. KLINIKUM DER UNIVERSITÄT MÜNCHEN® 7

http://vpsystems.virtualpatients.net


Is this really the best we can do?



Methods

1.  Stepping back: Developing a model for „Learning clinical reasoning“ 2.  Application of the model to virtual patients & elaboration of conclusions 3.  Development of a „clinical reasoning tool“ based on (2) 4.  Development of a virtual patient course 5.  Implementation of studies to explore learners‘ clinical reasoning process



Step 1: Grounded Theory

§  Grounded theory to explore the "learning of clinical reasoning" §  Aim: Development of an application-oriented model §  Data sources: Articles, videos, courses, interviews,... §  Documentation with memos and concept maps §  Discussion with an interdisciplinary expert panel



Results – Model

KLINIKUM DER UNIVERSITÄT MÜNCHEN® 11 INSTITUT FÜRpatients DIDAKTIK UND Hege I, Kononowicz AA, Berman NB, Lenzer B, Kiesewetter J. Advancing clinical reasoning in virtual - development and AUSBILDUNGSFORSCHUNG IN DER MEDIZIN application of a conceptual framework. GMS JME in press

Clinical Reasoning Tool


INSTITUT FÜR DIDAKTIK UND AUSBILDUNGSFORSCHUNG IN DER MEDIZIN Hege I, Kononowicz AA, Adler M. A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study. JMIR Med Educ 2017;3(2):e21

Course Development

§  70+ virtual patients in CASUS (en, de, and pl) together with Jaggielonian §  §  § 

13

University in Krakow, Poland Considering diversity (gender, sexual orientation, nationality, age,...) Videos explaining the tool & clinical reasoning Learner and Teacher Dashboard

KLINIKUM DER UNIVERSITÄT MÜNCHEN® http://videos.virtualpatients.net http://crt.casus.net INSTITUT FÜR DIDAKTIK UND AUSBILDUNGSFORSCHUNG IN DER MEDIZIN

Study 1

§  Analysis of clinical reasoning processes ("What is going on here?") §  Freely available courses (en and de), access via Shibboleth §  Data collection from Jan 1st until Jul 31 2017. §  1393 completed sessions with final diagnosis (317 learners) §  Three groups of maps identified



Study 1

Correct diagnosis on first try (59%)

Correct diagnosis on 2-x tries (13%)

Correct diagnosis revealed by system (28%)

Significant differences in the reasoning process Implications for research and assessment of clinical reasoning!



DISRUPTIVE: You: "Do you take any medication?" Study 2 Mr. Vogt: "I take pills for my high cholesterol, although I am not convinced §  How does the patient representation influence clinical reasoning that the pillslearners' really help. Sometimes I to take them and I don't feel worse." §  Six VPs with three different patientforget representations §  Disruptive patient behaviour / NEUTRAL: §  Friendly patient behaviour FRIENDLY You: "Do you take any medication?" §  No patient story, just facts presented Mr. Vogt: "I take pills for my high §  Randomized controlled study with cholesterol. 46 final yearI medical students take them regularly as you told me to." motivational questionnaire §  Analysis of usage pattern, diagnostic accuracy, §  Results: NOSTORY: §  Reliability of difficulty assessment? Medication: Cholesterol lowering pills §  Difficulty of the VP more influential than the design variations §  Disruptive behavior: More problems & tests §  Disruptive behavior & difficult VP -> Sig. lower diagnostic accuracy §  Story telling increases extrinsic motivation

§  Attention on difficulty of learning activtities and context variations 16

KLINIKUM DER UNIVERSITÄT MÜNCHEN® Hege I*, Dietl A*, Kiesewetter J, Schelling J, Kiesewetter I. How to tell a INSTITUT Patient's Story? of UND the Case Narrative Design on the Clinical FÜR Influence DIDAKTIK Reasoning Process in Virtual Patients. Submitted to Med Teach.*equally contributed AUSBILDUNGSFORSCHUNG IN DER MEDIZIN

Study 3

§  Do different ways of feedback influence time on task and usage pattern? §  Process versus outcome-oriented feedback (randomized controlled study) §  Pilot study with 64 medical students at Jagiellonian University, Kraków, §  §  § 

17

Poland and 16 VPs Spaced provision – Four VPs / week 873 maps with 19.689 nodes and 641 connections were created Completed avg. 15.8 VPs

KLINIKUM DER UNIVERSITÄT MÜNCHEN® Hege I, Kononowicz AA, Nowakowski M, Adler M. Implementation of process-oriented feedback in a clinical INSTITUT FÜR DIDAKTIK UND reasoning tool for virtual patients. IEEE 30th International Symposium on Computer-Based Medical Systems AUSBILDUNGSFORSCHUNG IN DER MEDIZIN (CBMS), 2017

Study 3

§  No significant difference in number of nodes between groups ( comparable §  §  § 

to expert) No significant difference in time on task PF: 87.5% of the nodes were added without consultating the expert's map Very low number of connections in both groups (Expert avg: 7.7/map) Average number of connections

Average number of nodes 33

2,5

28

2 1,5

23

1

18

0,5

Week 1

0 Week 1

Week 2

End Feedback

Week 3 Process Feedback

Week 4

Week 2

End Feedback

Week 3

Week 4

Process Feedback

® UNIVERSITÄT MÜNCHEN Hege I, Kononowicz AA, Nowakowski M, Adler M. Implementation of process-orientedKLINIKUM feedback inDER a clinical reasoning tool for virtual patients. IEEE 30th International Symposium on Computer-Based Medical Systems (CBMS), 2017 18 INSTITUT FÜR DIDAKTIK UND

AUSBILDUNGSFORSCHUNG IN DER MEDIZIN

What is next?

§  We need structured "Train the trainer" programs for clinical reasoning §  There is a need for a (blended,longitudinal) clinical reasoning curriculum §  Survey planned for needs analysis §  Longitudinal curricular integration of the VPs (blended learning) §  Combination with face-to-face teaching scenarios §  Integration into (E-)Portfolios (reflection, feedback) §  Deliberate practice: Many more (adaptable) VPs needed §  Use in interprofessional settings and other healthcare professions §  Further studies and development, e.g. concerning adaptability, difficulty §  § 

assessment, scoring,... Bridging the gap between preclinical and clinical years? "What about if there is no diagnosis?"



Take-home Message

§  Tool, virtual patients, and model can help structuring the clinical reasoning §  § 

learning Considering aspects of virtual scenarios, such as narrative design, level of difficulty, ... is important More explicit teaching of clinical reasoning is needed for both, educators and students



Thank you! Contact:

[email protected]

More information: www.virtualpatients.net

This project receives funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement no 654857

