The term virtual patient is used to describe interactive computer simulations used in health care education to train students on clinical processes such as making diagnoses and therapeutic decisions. Virtual patients attempt to combine modern technologies and game-based learning to facilitate education, and complement real clinical training. The use of virtual patients is increasing in healthcare due to increased demand for healthcare professionals and education of healthcare trainees, and provides learners with a safe practice environment. There are many formats from which a virtual patient may be chosen, but the overarching principle is that of interactivity . Virtual patients typically have mechanisms where information is parsed out in response to the learners, simulating how patients respond to different treatments. Interactivity can be created with questions, specific decision-making tasks, as well as text composition, and it is non-sequential . Most systems provide quantitative and qualitative feedback. In some cases, virtual patients are not full simulations themselves, but are mainly based on paper-based cases. This is because they do not allow for physical examination or an in-depth medical history of an actual patient. There are certain drawbacks, as crucial clinical findings may be missed due to the lack of examining patients in person.
32-434: Virtual patients may take several different forms: Several different modes of virtual patient delivery have been defined: Research has shown that utilizing virtual patients is time-efficient and cost-effective for developing clinical reasoning skills in students through independent and repeated practice of physician tasks in a safe environment without the risk of harm to the patient or learner, which can significantly increase
64-428: A simulated patient ( SP ), also known as a standardized patient , sample patient , or patient instructor , is an individual trained to act as a real patient in order to simulate a set of symptoms or problems. Simulated patients have been successfully utilized for education , evaluation of health care professionals, as well as basic , applied , and translational medical research . The SP can also contribute to
96-539: A checklist that the SP could use to evaluate the performance of the trainee. Dr. Paula Stillman trained another set of standardized patients in 1970 at the University of Arizona . Her pilot program had local actors portray the "mothers" of imaginary children. The actors would describe the illness the unseen child was suffering from, requiring the medical students taking the history to develop differential diagnoses based on
128-415: A circuit of short stations, usually 5–10 minutes, though some use up to 15 minutes. In each station, the candidate is examined on a one-to-one basis with one or two examiner(s) and either real or simulated (actors or electronic patient simulators) patients. Each station has a different examiner, as opposed to the traditional method of clinical examinations where a candidate would be assigned to one examiner for
160-787: A limited area only. Multiple encounters may be needed for broad ranged training or testing. Also, while SPs are quite proficient in simulating the symptoms , emotional states and even certain examination findings ( neurological examination , for example), they may not be able to simulate certain other signs such as heart murmurs or lung sounds . Recruitment of SPs may also be difficult, time-consuming and more expensive than using 'real' patients. SPs need to draw on their own personal experiences with physicians, conversations with healthcare professionals, talking to specific patient populations etc. They also need to be trained to accurately and reliably simulate particular clinical scenarios. Frequent quality assessment may be needed to ensure consistency in
192-495: A minimum number of stations required to pass which ensures that a consistently poor performance is not compensated by a good performance on a small number of stations. There are, however, criticisms that the OSCE stations can never be truly standardized and objective in the same way as a written exam. It has been known for different patients / actors to afford more assistance, and for different marking criteria to be applied. Finally, it
224-412: A part of an objective structured clinical examination . Typically, the SP will use a checklist to record the details of the encounter. SPs have also been sent unannounced into a physician practices to evaluate the standards of care. They are also employed as field researchers on health informatics projects. They can also assist in the development of seminars and lectures in an academic setting, under
256-441: A standardized assessment method. Simulated patients can be viewed as educational tools that enhance existing methods of clinical teaching, making them more efficient and increasing the fairness of skill evaluation. Over-reliance on hypothetical "average" models has been criticized for not teaching medical students to identify the significant amount of normal variation seen in the real world. The MedBiquitous consortium established
288-422: A standardized mark sheet. One of the ways an OSCE is made objective is by having a detailed mark scheme and standard set of questions. For example, a station concerning the demonstration to a simulated patient on how to use a metered dose inhaler (MDI) would award points for specific actions which are performed safely and accurately. The examiner can often vary the marks depending on how well the candidate performed
320-461: A typical OSCE scenario and timing it with one person role playing a patient, one person doing the task and if possible, one person either observing and commenting on technique or even role playing the examiner using a sample mark sheet. Many OSCE textbooks have sample OSCE stations and mark sheets that can be helpful when studying in the manner. In doing this the candidate is able to get a feel of running to time and working under pressure. In many OSCEs
352-545: A working group in 2005 to create a free and open data standard for expressing and exchanging virtual patients between different authoring and delivery systems. This was in part to address the problem of exchanging and reusing virtual patients and in part to encourage and support easier and wider use of virtual patients in general. This standard has been very successful and is now widely adopted, e.g. in major projects like eViP. In 2010, this standard attained status as an ANSI standard. Simulated patient In health care ,
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#1732802431541384-402: Is done by giving all candidates the same stations (though signs of real patients may vary slightly), where they are assessed with the same marking scheme and awarded marks for each step performed correctly. If theoretical knowledge is examined, such as with the examiner asking questions at the end of the station, the questions will also be standardised. The candidate will only be asked questions on
416-413: Is essential to dissect the method into its individual steps, learn the steps, and then learn to perform the steps in a sequence. Most hospitals and universities have clinical skills labs where students have the opportunity to practice clinical skills such as taking blood or mobilizing patients in a safe and controlled environment. It is often very helpful to practise in small groups with colleagues, setting
448-451: Is not uncommon at certain institutions for members of teaching staff be known to students (and vice versa) as the examiner. This familiarity does not necessarily affect the integrity of the examination process, although there is a deviation from anonymous marking. However, in OSCEs that use several circuits of the same stations the marking is repeatedly shown to be very consistent which supports
480-1171: Is now the USMLE Step 2 Clinical Skills exam and is mandatory for obtaining medical licensure in the United States, for both foreign medical graduates and American medical students. Since 2004 SPs have been used to assess the clinical competencies of osteopathic medical school candidates in the COMLEX USA Level 2-Performance Evaluation. Simulated patients (SP) are extensively used in medical and nursing education to allow students to practice and improve their clinical and conversational skills for an actual patient encounter. SPs commonly provide feedback after such encounters. They are also useful to train students to learn professional conduct in potentially embarrassing situations such as pelvic or breast exams. SPs who perform such training are given titles such as Gynecological Teaching Associate (GTA) or Urological Teaching Associate (UTA), as covered in more detail below. SPs are also used extensively in testing of clinical skills of students, usually as
512-411: Is very different from preparing for an examination on theory. In an OSCE, clinical skills are tested rather than pure theoretical knowledge. It is essential to learn correct clinical methods, and then practice repeatedly until one perfects the methods whilst simultaneously developing an understanding of the underlying theory behind the methods used. Marks are awarded for each step in the method; hence, it
544-468: Is where a medical professional, a preceptor, teaches the medical student how to perform the examination using a simulated patient as the model. For nursing, SPs are successfully supporting large cohorts of students in the undergraduate curricula. The use of simulated patients has several advantages: The largest limitation of simulated patients use can be their cost. At the same time, SPs are case specific and are able to assess clinical competency in
576-483: The British Medical Journal in 1975, OSCE has been widely adopted in many medical schools and professional bodies. The format of OSCE is continuously evolving and may include real or simulated patients, clinical specimens, and other clinical materials. OSCE is primarily used to assess focused clinical skills such as history taking, physical examination, diagnosis, communication, and counseling. In
608-403: The candidate scored. The examiner is usually asked to rate the candidate as pass/borderline/fail or sometimes as excellent/good/pass/borderline/fail. This is then used to determine the individual pass mark for the station. Many centres allocate each station an individual pass mark. The sum of the pass marks of all the stations determines the overall pass mark for the OSCE. Many centres also impose
640-445: The development and improvement of healthcare protocols; especially in cases where input from the SP are based on extensive, first-hand experience and observations as a clinical patient undergoing care. Dr. Howard Barrows trained the first standardized patient in 1963 in University of Southern California . This SP simulated the history and examination findings of a paraplegic multiple sclerosis patient. Dr. Barrows also developed
672-474: The entire examination. Candidates rotate through the stations, completing all the stations on their circuit. In this way, all candidates take the same stations. It is considered to be an improvement over traditional examination methods because the stations can be standardised , enabling fairer peer comparison and complex procedures can be assessed without endangering patients health. OSCEs are designed to assess candidates' clinical skills more objectively. This
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#1732802431541704-485: The last three decades the OSCE has seen a steady exponential growth and usage in both undergraduate and postgraduate examinations around the globe. OSCEs are also used for licensure examinations and as a feedback tool in formative settings. Common uses of the OSCE include: Objective structured clinical examinations evaluate learners "showing how" to perform complex clinical tasks including those infrequently observed and those core to practice. An OSCE usually consists of
736-421: The marking scheme, and will not be awarded marks for any other questions asked. OSCEs are also designed to be structured, with instructions carefully written to ensure that the candidate has a very specific task to complete in each station. Where simulated patients are used, detailed scripts are provided to ensure that the information provided is the same for all candidates, even including the emotions displayed by
768-528: The mental pool of learned cases in students. Unlike simulated or real patients, virtual patients can be accessed on demand, and the user may monitor a case over several months while spending less than an hour in real time. Furthermore, virtual patients can be endlessly replayed and easily modified to allow the user to explore different clinical scenarios and patient outcomes. Compared to simulated patients , virtual patients make observation and assessment more robust and easier to control, and they can be used as
800-502: The mother's testimony. In 1984, a number of residency programs in the northeastern U.S. , gave their residents the same examination using SPs. The Medical Council of Canada was the first to use SPs in a licensure examination in 1993. The Educational Commission for Foreign Medical Graduates introduced the Clinical Skills Assessment exam in 1998 to test the clinical skills of foreign medical graduates. This exam
832-402: The objectivity of the examination which is basically an organization framework consisting of multiple stations around which students rotate and at which students perform and are assessed on specific tasks. OSCE is a modern type of examination often used for assessment in health care disciplines. The development of OSCE is credited to Ronald Harden. Since the publication of the first paper in
864-454: The patient. The examination is carefully structured to include parts from all elements of the curriculum as well as a wide range of skills. There are several variations of OSCE, those are: The advantages of OSCE are: The disadvantages of OSCE are: Marking in OSCEs is done by the examiner. Occasionally written stations, for example, writing a prescription chart, are used and these are marked like written examinations, again usually using
896-427: The portrayal of the patient role; especially since SPs may absorb a significant amount of clinical knowledge from their interactions with healthcare professionals. Objective structured clinical examination An objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components are assessed in a planned or structured way with attention being paid to
928-416: The stations are extended using data interpretation. For example, the candidate may have to take a brief history of chest pain and then interpret an electrocardiogram . It is also common to be asked for a differential diagnosis , to suggest which medical investigations the candidate would like to do or to suggest a management plan for the patient. The peer-assisted mock OSCE improved tutee confidence, reduced
960-457: The step. At the end of the mark sheet, the examiner often has a small number of marks that they can use to weight the station depending on performance and if a simulated patient is used, then they are often asked to add marks depending on the candidates approach. At the end, the examiner is often asked to give a "global score". This is usually used as a subjective score based on the candidates overall performance, not taking into account how many marks
992-575: The supervision of full or associate professors. SPs can also serve as a "confederate" in a simulation to perform the roles of other clinicians within the care team. SPs used for in situ simulation activities may require special training. For teaching future healthcare professionals how to perform intimate examinations, a specially trained simulated patient may be used. Intimate examinations include breast and pelvic examination on females and urogenital, prostate and rectal examination on males. Such roles are known by various names. One form of instruction
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1024-450: The validity that the OSCE is a fair clinical examination. There are arguments for and against quarantining OSCE examinees to prevent sharing of exam information. Although the data tend to show no improvement in the overall scores in a later OSCE session, the research methodology is flawed and validity of the claim is questionable. A study suggested that marks do not give a sound inference of student collusion in an OSCE. Preparing for OSCEs
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