Computer-based Instruction for Making Better Doctors

Economic forces have caused the primary setting for disease management to shift from the inpatient to the ambulatory setting, where biomedical advances have allowed diagnostic procedures and therapeutics to take place in lower-cost clinic settings rather than inside hospitals. However, the bulk of clinical training still occurs in the hospital, where students are exposed to diseases that are not reflective of illnesses in the general population. Pressures to shorten hospital stays have resulted in lost opportunities to interact with and learn from patients. Another result of this shift is that medical students, novices in the healthcare team, become marginalized rather than engaged in the clinical decision-making process.

Computer-based technology, although not a panacea, can enhance medical education by broadening the spectrum of clinical experiences and content to which learners may be exposed. In addition, delivery via the Internet (characteristic of many of these programs) provides and organizes information at learners’ fingertips, when it is most needed. Computer-based instruction (CBI), in which education is central to the program, should be distinguished from general computer-based resources, such as

online textbooks and search engines.

For medical students in their early years of training, websites focusing on the physical exam are most popular. Whether featuring lung sounds or displaying videos of the musculoskeletal exam performed by experts, these sites provide immediate and practical benefits to medical students as they learn to distinguish between normal and abnormal findings. Additionally, sophisticated graphical representation combined with animation creates a visualization paradigm that static diagrams in textbooks cannot match.

The heart sounds tutorial created by Blaufuss Multimedia is a notable example of this technology. It features a multi-layered presentation of the heart; moving the mouse over component labels causes the layers to appear and disappear dynamically, so that the user recognizes the complex relationship between the musculature, vascular, and bony structures of the chest. Another section traces the path of blood through various chambers of the heart, while synchronizing the heart sounds with valve closures, pressure waveforms in the diff erent heart chambers, and the EKG tracing. Medical students often learn these components separately without understanding how they interrelate. Incorporating dynamic new technologies into the instructional process will help learners to synthesize the concepts, likely leading to better retention and advanced application of information.

Another excellent example of CBI is the Eye Movement Simulator, created at the University of California Davis School of Medicine. This tool allows medical students to create muscular and cranial nerve palsies and observe their effects on eye movements. Although students may rarely encounter a real patient with abnormal eye movements, it is critical that they learn

the skill of correlating findings with their neurological basis.

Physical exam applications like the ones mentioned focus on the early years of medical school training; case-centered tools help instruct medical students during their clinical years. In particular, “virtual patients” were designed to fill gaps in clerkships by exposing students to diseases that they would not otherwise experience due to short clinical rotations and limited ambulatory experiences. Virtual patients are defined as “computer programs that simulate real-life clinical scenarios in which the learner acts as a health care professional obtaining a history and physical exam and making diagnostic and therapeutic decisions.”

An example of a virtual patient from Harvard Medical School simulates the longitudinal care of a diabetic patient over the course of nine “virtual” years, condensing the case into several hours as it moves from diagnosis to the treatment of comorbidities, to the development of microvascular complications, and the initiation of insulin. Virtual patients can be used to expose learners to rare, “do-not-miss” events, such as ruptured aortic aneurysm, that might not occur during a three-month clerkship or even a three-year residency. They may permit a window into procedures such as a cardiac catheterization or initiate conversations in which trainees may not normally participate, such as a primary care physician giving bad news to a patient.

SIMULATING TEAM INTERACTIONS

As the technology grows more sophisticated, so do the tools available for training our future health professionals. One of the most advanced applications of technology for medical education stems from work done at Stanford University School of Medicine in collaboration with Forterra, Inc., a software company. Developers have created a three-dimensional reproduction

of a physical treatment setting, in which participants may role play as nurses, physicians, emergency personnel, and patients by manipulating and communicating through avatar representations, much like the social networks formed on Second Life. A variety of scenarios and situations can be simulated; in one, participants must work as a team to triage and provide appropriate medical care for victims of a dirty bomb explosion. One advantage offered by the online format is that participants neither have to congregate in person to practice team training, nor are they limited by physical space to rehearse various medical scenarios.

The value of CBI arises from the rationale for simulation in general—the ability to practice skills of diagnosis and management without causing harm. Students experience the consequences of bad decision making in a memorable fashion but without exposing patients to injury. These programs also mitigate the negative effect of time and clinical opportunity on learning; students currently learn only what they happen to encounter and may never experience rare but important entities like anaphylactic shock. Virtual patients in particular offer the ability to manipulate time to enhance learning—for instance, speeding it up so you see the late complications of diabetes or slowing it down so the student can think about an abnormal EKG and go through the various steps of interpretation.

There are, of course, limitations to CBI. It is only meant to be a complement to the primary role of real patients for medical education. Communication skills, for instance, may not be as easily taught because the technology may not portray the interactions realistically, and in such cases, may need to rely on trained patient actors or on mannequin simulators. Additionally, computers cannot replace the role of the physician as mentor and role model.

THE FUTURE IS QUICKLY APPROACHING

The technology has advanced faster than researchers’ abilities to evaluate it. Studies in other domains, such as cognitive psychology and secondary education, show benefit from CBI compared to traditional methods of learning, but current studies in medical education are limited in subject size and generalizability. However, one of the most compelling anecdotal endorsements of CBI came from a French-Arab patient who viewed a video tutorial of the pelvic exam (go to this link and click on “Pelvic Exam”) and relayed how much the videos had dispelled her fears before her first pelvic exam. It is a stark reminder that the focus of medical education must ultimately translate into benefi ts in patient care.

The future will bring further research and understanding about which applications of CBI are benefi cial and which are not. We will continue to see more hybrids between haptic touch devices (technology that uses vibrations, motion, and other forces to interface with the user via the sense of touch) and screen-based technologies, the spread of virtual reality applications, and enhanced artifi cial intelligence for communication and other interpersonal skills. Medical education will rely more on situated learning; that is, education will be at the point-of-care in response to immediate needs for information. Bounded only by human creativity and driven by the perpetual need for safe and eff ective medical training, the potential benefit of technology in training our future physicians seems limitless.

Grace Huang, MD, is the Director of Assessment at the Carl J. Shapiro Institute for Education and Research at Harvard Medical School (HMS) and Beth Israel Deaconess Medical Center (BIDMC). She is an assistant professor of Medicine at HMS and a hospitalist at BIDMC. She designs computer-based modules focusing on clinical skills, including physical diagnosis tutorials, interactive diagrams, and procedure-based instruction. She is also an expert on the use of virtual patients and computer-based simulations of clinical scenarios.