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SOLSTICE 2007 Conference, Edge Hill University 1
A Workable Model for Virtual Patient Design
Dr Jonathan Round, Emily Conradi, Dr Terry Poulton,Arnold Somasunderam
e-Learning Unit, CMHCE, St George’s University of London,econradi@sgul.ac.uk ABSTRACT
St George’s University of London have created a generic ‘model’ for virtual patient (VP)design, simple enough for clinicians to use, yet flexible enough to simulate real clinicaldecisions. This method of VP creation is disseminated to educators within our institutionthrough regular VP workshops.For each VP an ideal pathway is described, with 3 or 4 critical points or ‘nodes’ that thepatient must pass, in order to progress through the case. These might be, for example,the restoration of cardiac output after an arrest, ward transfer, or referral to anotherdoctor.In order to navigate between nodes, a map of different interconnected possibilities isdesigned, typically with 3-4 steps and 3-4 choices at each step. Choices at each stepmimic some of the choices that would be available for a real patient. Many of thesewould not allow progress to the next node.The online activity modeling system ‘Labyrinth’, developed by the University ofEdinburgh, allows these ideas to be quickly and easily transferred into a digital virtualpatient. Labyrinth offers an easy to use VP creator and player that conforms to the latesttechnical standards. The finished VP can be accessed online or through an institutionalVLE, with optional add-ons such as timing and scoring.As a result, a simple educational model can be used to create ergonomically designedVPs. The next step will be to determine how to incorporate the generated VPs into ourmedical curriculum. A trial study to replace our current PBL-based curriculum with a VPcurriculum is being piloted. VPs for the clinical years are to be developed for mobiledevices, to provide the students with ‘just-in-time’ learning.
KEYWORDS
 
SOLSTICE 2007 Conference, Edge Hill University 2
Virtual patient, medicine, healthcare, higher education, decision-making, gaming
WHAT IS A VIRTUAL PATIENT?
A virtual patient (VP) is defined as: “an interactive computer simulation of real-lifeclinical scenarios for the purpose of medical training, education, or assessment.”(Ellaway, Candler et al., 2006). In its simplest form a VP allows the user, usually via acomputer, to make a choice based on some clinical information. The user is then givenfeedback dependent on their choice. More complex VPs will offer more choices, andthen link pages together, so that the information and choices available at any stagedepend on the choices made earlier in the scenario.Although virtual patients come from a medicine and healthcare perspective, VPs areessentially problem-solving exercises – the user must apply knowledge to progressthrough the scenario (Henderson, 1998). If the case is reflective of real situations andreal choices, they can be excellent tools to practice using knowledge, reasoning, anddecision-making skills, applicable in many fields.Practising knowledge and skills using virtual patients can offer some advantages overlearning through real-life practise including:
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Repetition;
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Consistent feedback;
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A potential for a greater exposure of scenarios;
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Mistakes do not carry real world repercussions;
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The ability to investigate alternative courses of action;
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Learning can be undertaken in a time and place convenient to the learner.Simulators and games such as VPs have proven effective and popular e-learning tools(Aldrich, 2005; Quinn, 2005) that can underpin and extend current practice in teachingand learning. In particular Virtual patients have already been used with success forstudent learning and training in healthcare (Bergin & Fors 2003).Professional and vocational education needs to be as close to real practice as possible,whilst still offering educational opportunities and activities. It is emulating real practicethat makes the design of VPs a challenging task.
 
HOW TO MAKE A VIRTUAL PATIENTApproaches to virtual patient design
VPs can be time-consuming and expensive to produce. There are four distinctapproaches to virtual patient design:
 
SOLSTICE 2007 Conference, Edge Hill University 3
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The linear approach
. Here the user is prevented from going down any wrongpaths by immediate correction. This is clinically unrealistic, where there are oftenseveral ways to tackle a problem and mistakes are often not immediatelyobvious. This approach might be used for testing knowledge of a protocol, butwill not engage students in the same way as more complex, multi choice VPs. Anexample of a linear case of this sort is paper-based problem-based learningcase, where the case only proceeds in a single direction.
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The Hi-Fi approach 
. This approach demands a large amount of time, moneyand effort to model all of the possible choices the VP writing team can think of.Effort is then spent on linking the case to other media and on the appearance ofthe case. This is an expensive process – Dr J.B McGee from the University ofPittsburgh has estimated the cost at over $100,000 per case, making the creationof a large VP bank impossible for institutions, even collaboratively. Patientsimulators such as those used to train emergency medicine staff andanaesthesiologists
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are becoming more available, although their purchase priceand running costs are large. These offer the ‘ultimate’ in hi-fi virtual patients.Even so these might not be suitable for a large range of history based ofinvestigation based scenarios.
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The algorithm method
. Here formulae are developed that mimic physiologicprocesses in the body and in disease states, so that changes made by the user(typically administration of drugs or fluids) alter the output of the formulae andproduce changes on the display, typically of biophysical variables. However thisapproach can only be used to create VPs where alterations in vital signs orbiochemistry are the main elements of the case, such as anaesthesia, metabolicmedicine or critical care pharmacology. Most of clinical medicine cannot betackled in this way, as it is descriptive and history based. An example is theVirtual Center for Renal Support (Prado et al., 2002).
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The Lo-Fi method 
. Here effort is spent on creating a large, but limited number ofchoices. Users are allowed to make around 2-3 wrong choices before finding outtheir mistake. They are given the option, after making a wrong choice, of makingthe correct choice, as long as the choice was not dangerous. These cases areoften not as media-rich or as interactive as hi-fi cases. The interaction will focuson a specific set of options rather than a much broader set of choices. Anexample of a lo-fi VP is Sarah-Jane, developed at St George’s University
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The problem of choice
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Example of a hi-fi patient:http://anesth.utmb.edu/simcenter/ [last accessed 23/03/07]
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Example of a lo-fi patient:http://www.elu.sgul.ac.uk/virtualpatients/examples/sarah_jane/SJP_h_21_NT_HM.html [last accessed 23/03/07]
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