eLearning in medical education: Explore the virtual patient

Davis Dewhurst

David Dewhurst (BSc, PhD) is Professor of eLearning and Director of the Learning Technology Section in the College of Medicine & Veterinary Medicine at The University of Edinburgh. He is an international figure in eLearning research in the bio/medical domain and has published widely in this area. He is also Principal Investigator for a number of eLearning grants. The eLearning Unit of the Learning Technology Section was recently awarded one of the prestigious Queen’s Anniversary Prizes for HE and FE. His main partner in the Malawi Virtual Patient Project is Eric Borgstein, Professor of Surgery at the Queen Elizabeth Hospital, Blantyre and Postgraduate Dean in the College of Medicine, University of Malawi, Blantyre.

eLA: Professor Dewhurst, from your point of view, how can eLearning serve to improve medical teaching and lecturing?

David Dewhurst: Medical education is most successful when learning occurs in context. One way of achieving this online is by using virtual patients for whom a student may take different roles – junior doctor, consultant, nurse or even as patient himself. In these roles, they are presented with a digital scenario describing the patient and the details of the case. The doctor may need to simulate taking a history, carrying out an examination, ordering tests, interpreting test data or images or making a diagnosis and prescribing treatment.

Working through these scenarios is very effective in learning and applying knowledge and in learning decision-making skills. Of course a lot of this could be better achieved by students working with a broad range of real patients in the presence of a knowledgeable tutor. However, in the UK at least, changes in clinical practice have meant that opportunities for such encounters with real patients are becoming increasingly limited.

eLA: What is your idea of self-directed learning in this context?

David Dewhurst: Examples of using technology to support such educational processes might include the use of discussion boards in which tutors can present students with questions, and learning occurs from the responses of their peers who contribute to the discussion. Similarly, groups of students might collaborate to generate knowledge using a wiki or producing a website. Enabling students to engage with online resources and participative and collaborative learning opportunities ensures that students are actively engaged in managing their own learning. In Edinburgh, examples of all of these methods are used to support medical education within a blended-learning environment in which face-to-face and online learning are combined to deliver a much more participative learning experience and an enhanced learning environment.

eLA: Can you tell us more about your activities in Africa?

David Dewhurst: The project I am leading has the goal of training the trainers: Target groups are those working in higher education in Malawi, teaching students of medicine, nursing and clinical officers. The number of participants on these courses is planned to increase dramatically to fulfil the needs of the health service.

The training being provided is focussed around three workshops. The first, in April 2007, focussed on development of storyboards for online resources in the form of virtual patients. The second, coming up in April 2008, will focus on the further transformation of paper-based storyboards into online resources, and the third, planned for October 2008, will focus on the integration of these online resources into the curricula.

Curricula for these groups are currently undergoing significant revision, and there is a wish to move towards more interactive resources that will support active, student-centred learning rather than the predominantly passive didactic teaching that exists now. The technological infrastructure is improving at a rapid rate, and all three Colleges are becoming increasingly well equipped.

eLA: Why the focus on Malawi?

David Dewhurst: Scotland currently has a special relationship with Malawi in terms of a political cooperation agreement. A large proportion of Scottish international development funds are targeted at Malawi, and in fact, our project is funded by the Scottish government.

eLA: How can one envision a virtual patient? Would you please explain the concept?

David Dewhurst: In the context of this project, a VP is a computer model of a real patient case, which can then be presented on a PC – or paper and mobile – for students to interact with. VPs can be created to help students learn key clinical skills: taking a history; doing a physical examination; ordering tests, e.g. blood tests, x-rays or other images; interpreting the results of these tests; and undertaking diagnosis and treatment.

There are a variety of ways of presenting a VP. For instance, they may be fairly structured in that students work through a typical patient case, e.g. a patient suffering from HIV/AIDS; patients with obstetric or gynaecological problems; or patients suffering from different infectious diseases. In this instance, the students would be presented with a brief medical history. They might then see a video of a doctor interviewing the patient and then carrying out an examination. They would select which tests they wanted to order, receive the test results, interpret the results, make an initial diagnosis, order more tests or refer the patient to a specialist, refine the diagnosis, prescribe treatment, and so on. In different VPs, the student might take the role of a family doctor, a specialist consultant, a nurse, a laboratory scientist, a midwife or even the patients themselves.

This type of learning is highly interactive, and students make choices throughout and learn from an online tutor who guides them through the VP scenario, giving feedback when they make inappropriate decisions, etc.

eLA: How does this learning from mistakes work?

David Dewhurst: VPs may also be less structured such that students are ‘allowed’ to make incorrect decisions and follow a path that might result in them ordering expensive tests that are inappropriate, making incorrect diagnoses and prescribing inappropriate treatments. In some cases, a combination of these might even result in the death of the patient. In this situation, learning is exploratory, may be collaborative and can be particularly effective. Creating quality VPs is challenging but ultimately very rewarding.

eLA: Could you tell us more about the IT tools you use to transform offline resources into online content?

David Dewhurst: We use a web-based authoring tool developed at the University of Edinburgh called Labyrinth. This particular tool is relatively simple to use and therefore suited to the academic trainers who in the main do not have highly developed technical skills. An intermediary tool called VUE is also used to take the initial written storyboard into an electronic format and to get the basic structure. In our experience, both VUE and Labyrinth are ideal for the project, and it is anticipated that the HE trainers in Malawi will have few difficulties in learning how to use these tools at the April workshop. Indeed a number of them started to use the tools with little introduction at the end of the April 2007 workshop.

Currently learning technologists at the University of Edinburgh are transforming the storyboards from the workshop into online resources using VUE and Labyrinth. To date we have created about 15 VPs in this way. The hope is that following the April 2008 workshop, the Malawi trainers will be able to do this for themselves and perhaps more importantly, be able to pass on their knowledge and skills to colleagues.

eLA: In April 2007, you started the virtual patients project. What experience and insights have you gained?

David Dewhurst: We were extremely impressed by the rapid progress made by the twenty workshop participants who successfully created very engaging storyboards for about ten VPs during the three-day workshop. Since then, a number of other VPs have been added by the participants.

eLA: What are your future plans in terms of portability and sustainability?

David Dewhurst: Ultimately, the online VPs will be made freely available to Malawian HE institutions for use in both undergraduate and postgraduate training. Those same resources will also be available to Scottish HE, and there is no reason why they cannot be made available in a variety of formats – online, on CD-ROM, on mobile phones – to any country.

eLA: David, many thanks for your time.

Further links and resources:

College of Medicine and Veterinary Medicine at The University of Edinburgh http://www.mvm.ed.ac.uk/

College of Medicine, University of Malawi

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