Project summary

Shorter stays in hospital and increasing specialisation of hospitals restricts the access of students to real patients in the modern era, and VPs offer a unique opportunity to safely expose students to many patient presentations and diseases  they may not see in their clinical attachment, for safe practice.

This is the first medical education project aimed at targeting avoidance of error by deliberately allowing students to make errors safely, i.e without damage or injury to patients.  It takes advantage of the students’ emotional engagement to make safe practices more memorable. Technologically it is promoting the use of open-source software applications as the only realistic contender for tackling a difficult educational challenge;  providing authentic immersive ways of training students and learners to develop clinical reasoning skills  in practice-based element of medical education. Pedagogically this project  addresses a fundamental issue in clinical management, to safely train learners in making correct decisions, without compromising patient safety and without requiring exposure to every clinical  situation  or disease the student may need to be familiar with.

Objectives

The specific objectives of TAME are:

  • to develop a Virtual Patient methodology based on virtual case histories to enable  future physicians to avoid most common medical errors in the diagnostic and therapeutic process on a safe environment  before exposure to real patients;
  • to transfer knowledge and experience from the institutions which have already gone through a successful implementation of learning methods in paediatrics, develop paediatric (modules) in each institution as exemplar studies;
  • to use the experiences gained in the exemplar study to create similar resources in different clinical attachment areas  in each institution;
  • to use supra-regional ePBLnet, MEFANET, and other medical education networks to create, share and disseminate these multi-lingual, multi-cultural resources  aimed  at avoiding or decreasing medical errors.

With achievement of TAME’s objectives, a great need for the changes in the national healthcare systems will be fulfilled. The training methodologies will be improved, in order to minimise morbidity and mortality resulting from medical errors. Thus, healthcare costs will decrease, the quality of therapy will increase and the public trust in physicians and medicine will be enhanced.

The resulting innovated medical curricula will be consistent with the efforts of the accreditation councils for graduate medical education as well as of the national expert medical associations. Medical schools play key roles in resolving all barriers that may hinder transparency and full disclosure of medical errors. Training against medical errors will serve as the basis for enhancing patient-doctor relationships, limiting further harm and improving overall healthcare safety.

Background – dealing with medical error

Currently the clinical training in medical education, worldwide, teaches a student ‘how to do it right’. It avoids looking at how and why people can ‘get it wrong’. It does not teach how to try and avoid the same thing happening again. After a campus-based period of clinical science and skills training,  most clinical training is carried out in the ‘clinical years’ through apprenticeship, an exploratory and experiential method which effectively means practicing on patients. Safety training mechanisms are largely either reactive or systemic devices making erroneous actions difficult to take.

This approach has been shown to severely compromise patient safety (1). Progressive improvements in medical, surgical and pharmaceutical opportunities for treatment has made a major contribution to health, but it has also highlighted the emerging problem; medical error is now, in the developed world, one of the leading causes of death and harm in patients, and this newly-recognised major issue needs to be addressed through changes in education.

Many curricula in medicine are now built around interactive virtual patients, where students can explore, manage or solve a problem, including opportunity to make mistake and correct the one. Nevertheless there is still a large gap between formal university-based training which teaches how the students supposed to manage patients in the regular, appropriate way, and real practice with their challenges and threads. Medical schools in partner countries do not have any experience in training against errors. The EU countries accumulated required knowledge, skills, qualification in this area and they are proficient in sharing their achievements (through consultancy) internationally.

VPs are ideally suited to develop expertise in clinical reasoning through exposure to either a large number of cases, or a smaller number of cases with the possibilities for a variety of diseases built into the case narrative and virtual management opportunities. VPs allow students to experience medical error processes, often by making the wrong decision but in a safe environment, having the opportunity to discuss why it is happened.

An earlier EC programme eContentplus-funded project led by SGUL, eViP,  generated a bank of freely available VPs for Europe to encourage the wider use of learning based on realistic patient scenarios. In the initial project survey 90% of survey respondents from 19 countries supported the need for VPs in their curricula for realistic patient centred training. Building on this development, a UK-funded project Generation 4, SGUL created a new type of VP-based problem-based learning, in which  groups of students consider different options as an interactive case unfolded; take decisions, and  safely explore the consequences of their own management/solution (2).

In controlled trials with ‘interactive VPs’, students performed better in examination questions related to the interactive management elements in the case (3). VPs are now established widely in the SGUL curriculum, encouraging students to use their knowledge base to explore simple management decisions as they work through patient scenarios. 

Two current EC projects build on these findings. The Tempus-funded ePBLnet epblnet.eu modified the campus-based medical curricula of six institutions in Georgia, Ukraine and Kazakhstan by embedding virtual patients in PBL. This project has been largely focussed on modernizing the teacher-based and classroom-oriented biomedical science component of the medicine and health care courses, to put basic and clinical science in a patient context. The Erasmus+ funded CROESUS has gone one step further, taking VPs into the clinical apprenticeship stage of medicine and using VPs to teach clinical decision – making during the clinical apprenticeship phase of medical training.

This project will develop modules that would cover this approach. Interactive electronic scenarios are increasingly recognised by the medical education community as very effective tools for developing reasoning skills. This will lead to a more patient-centric view of medicine, improve the quality of medical treatment and decrease the healthcare costs through development and implementation of innovative teaching strategies (teaching against medical error using VP).

References:

(1) Young J et al. Ann Intern Med 2011; 155: 309-315
(2) Poulton T et al. Med Teach 2009; 31(8): 752-758
(3) Poulton T et al. J Med Internet Res 2014; 16(11): e240