Building a virtual patient commons

Virtual patients as a form of educational intervention can take many forms and can provide highly effective ways of addressing reduced student access to real patients, the need for standardised and well-structured educational patient encounters, and opportunities for students to practice in safe and responsive environments. However, virtual patients can also be complicated and costly to develop. As a result collaborative and distributed development is best suited to their widespread take up. This paper considers the development and use of virtual patients and the steps that have been taken to support authors in making this approach more sustainable and adaptable. In particular, this has involved the development of a common data interoperability standard, which in turn has engaged a number of communities that have developed, or are developing, virtual patient commons, consisting of shared resources, tools and knowledge for mutual benefit. The paper illustrates how innovative and otherwise difficult to sustain models for supporting and extending healthcare education, such as virtual patients, can be supported using a commons approach with commonly agreed data standards and specifications at their core.     

Not all unprofessional behaviors are equal: The creation of a checklist of bad behaviors

Introduction: Professionalism is a key component of medical education and training. However, there are few tools to aid educators in diagnosing unprofessional behavior at an early stage. The purpose of this study was to employ policy capturing methodology to develop two empirically validated checklists for identifying professionalism issues in early-career physicians.

Method: In a series of workshops, a professionalism competency model containing 74 positive and 70 negative professionalism behaviors was developed and validated. Subsequently, 23 subject matter experts indicated their level of concern if each negative behavior occurred 1, 2, 3, 4, or 5 or more times during a six-month period. These ratings were used to create a “brief” and “extended” professionalism checklist for monitoring physician misconduct.

Results: This study confirmed the subjective impression that some unprofessional behaviors are more egregious than others. Fourteen negative behaviors (e.g. displaying obvious signs of substance abuse) were judged to be concerning if they occurred only once, whereas many others (e.g. arriving late for conferences) were judged to be concerning only when they occurred repeatedly.

Discussion: Medical educators can use the professionalism checklists developed in this study to aid in the early identification and subsequent remediation of unprofessional behavior in medical students and residents.     

Breaking bad news: qualitative evaluation of an interprofessional learning opportunity

This paper analyses the effects of bringing together a small group of nursing and medical students to learn the skills needed to break bad news to patients. It outlines the qualitative and quantitative methods used, to provide the reader with a comprehensive account of the teaching, learning and research strategies drawn on during the study. The paper examines the evaluation phase, as this aspect is of greatest import if such initiatives are to flourish. The facet of the study analysed in detail concerns the students' responses to the open-ended qualitative questionnaires. In coding the data, three researchers independently highlighted a series of themes associated with the benefits and hazards of nursing and medical students learning and working together. Finally, the paper closes by arguing that trust and mutual respect are vital ingredients if collaborative working is to become part of the medical and nursing curriculum.     

A closer look at the bad deal trial: beyond clinical equipoise

Some commentators have recently proposed that "clinical equipoise," although widely accepted, is not necessary for morally acceptable research on human subjects. If this concept is rejected, however, we may find that trials not in the best medical interests of their subjects--"bad deal trials"--could be justified. To avoid exploiting participants, we must find a way to distribute the risks fairly, even if it means embracing radical changes in the way clinical research is conducted.     

Twelve tips for developing and maintaining a simulated patient bank

Simulated patients have become almost indispensable in the education and training of health care professionals. Their contribution to the creation of a safe, yet realistic, learner centred environment is invaluable. Their support in enabling learners at all stages of their professional careers to develop both competence and confidence through repeated practice helps to ensure that learning from real patients can be maximized. A simulated patient bank can enable tracking and training of simulated patients to be coordinated in an effective and efficient way both for patients and learners. This paper shares experiences of developing a simulated patient bank against the background of changes in health care delivery and education and training. Twelve tips to developing and maintaining a simulated patient bank have been identified. The tips focus on the needs of the simulated patient bank and ensure that training is at an appropriate level for the learners, patient care is not compromised and simulated patients feel they are valued members of the educational team.     

Speech and language difficulties in a patient with schizophrenia-like disorder: a case report

Neurocognitive complications, such as speech and language dysfunctions are common comorbids in psychiatric patients with underlying medical conditions, such as stroke. Ascertaining a diagnosis is not usually easy, especially in the hands of the primary physicians who first attend to such patients. In addition, making diagnosis purely on previous psychiatric presentations, without thorough neurological and neurocognitive evaluation, is a mistake psychiatrists should avoid. Cultural belief systems in Nigeria play important role in the choice of care people with psychiatric problems receive, and the dearth in the country's mental health personals is a be-deviling handicap to providers of mental health services in the country. The author presents the case of a 52 year old man with schizophrenia-like psychosis that was complicated by speech and language problems following a cerebrovascular accident. In conclusion, doctors especially psychiatrists should be alert to co morbid physical illnesses in patients with psychiatric presentations.     

Developing practical criteria for evaluating online patient simulations: a preliminary study

Online patient simulations are increasingly used in medical education. However, uniform criteria for evaluating simulations don't exist. This study explored expert opinion regarding the essential components of online simulations. Preliminary criteria were examined through a survey of 22 medical educators and follow-up interviews with nine educators. Features involving routine tasks and the teaching of problem solving skills-histories, physicals, labs, and differential diagnoses were highly rated. Features conveying realism such as time constraints and the use of multimedia were ranked lower. Interviewees noted three impediments to wider use of simulations: time required to develop content, limits of current technology and the absence of usable authoring tools.     

Persistent influence of a narrative educational program on physician attitudes regarding patient care

Purpose: Educational approaches involving patient stories aim at enhancing empathy and patient-centered care; however, it is not known whether the influence of such programs on physician attitudes persists beyond medical school.

Materials and methods: The Family Centered Experience (FCE) paired preclinical medical students with patient families over two years and engaged students in reflective dialogs about the volunteers’ stories. This study examined possible long-term influences on attitudes toward medicine and doctoring. Interviews were conducted with former students at the end of or after post-graduate training. All had completed the FCE between 4 and 10 years before the study. Thematic analysis was informed by a constructivist Grounded Theory approach.

Results: Several themes were identified. The FCE made graduates aware of the patients’ perspectives and impacted their clinical practice in specific ways, such as developing collaborative partnerships, conducting family meetings, and breaking bad news. The course had influenced career choices and interest in teaching. Finally, the FCE enhanced appreciation of the human dimensions of medicine, which graduates had drawn upon in subsequent years.

Conclusions: A program based on longitudinal interactions with individuals with chronic illness can have persistent influence by stimulating reflection on the patient’s perspective and humanistic approaches to patient care.     

Limits on patient responsibility

The medical profession and medical ethics currently place a greater emphasis on physician responsibility than patient responsibility. This imbalance is not due to accident or a mistake but, rather is motivated by strong moral reasons. As we debate the nature and extent of patient responsibility it is important to keep in mind the reasons for giving a relatively minimal role to patient responsibility in medical ethics. It is argued that the medical profession ought to be characterized by two moral asymmetries: (1) Even if some degree of responsible behavior from patients is called for, placing the dominant emphasis on professional responsibility over patient responsibility is largely correct. The value of protecting the right to refuse treatment and arguments against paternalism block a more expansive account of patient responsibility and support a strong notion of professional responsibility. (2) Insofar as we do want to encourage an increase in patient responsibility, we have good reasons to emphasize prospective rather than retrospective notions of responsibility in clinical practice. Concerns about patient vulnerability along with the determined factors in disease leave little room for blame at the bedside. These two asymmetries generate normative limits on any positive account of patient responsibility.