Invited lectures

The MEFANET 2010 conference includes two attractive plenary sessions consisted of invited lectures.

L. Dusek & D. Schwarz (Masaryk University, Czech Republic)
MEFANET after four years of progressing: 4-D model for digital contents quality assessment

Abstract: The idea of sharing educational digital contents among Czech and Slovak medical faculties occurred for the first time in 2006. Soon afterwards in 2007, all seven Czech medical faculties as well as all three Slovak medical faculties have formally joined the brand new network MEFANET (MEdical FAculties NETwork). One of its main objectives is enabling authors to publish their electronic teaching materials in a system without any licensing fees. MEFANET has decided to develop an original and uniform solution for educational web portals, which are used, together with a central gate, to offer and share digital educational contents. In this respect, a unique collaborative environment, which is full of shared resources, has been growing. It is rather an e-publishing system than a commonly known and used learning management system – LMS. The e-publishing system consists of ten standalone educational portal instances, which are run on each of the participating schools, and one central gate, which allows students to find study materials from all participating schools at once. The portal instances are connected to authentication services of the involved schools, so that students and staff do not have to define and remember ten new logins and passwords. Recent developments have been focused on a new set of tools for quality evaluation of the published contents. This set of tools is called here as „4-D model for digital contents quality assessment“ – the following four dimensions will be presented in detail: 1) review, 2) typological classification, 3) level of the target group, 4) users’ self-study score. The 4-D model promises a wider range of tools for organizing the published contents as well as a possibility to present the contents completed by comments from tutors selected from expert medical societies.

U. Fors (Karolinska Institutet, Sweden)
Virtual patients and other virtual environments for learning, assessment, diagnosis and treatment

Abstract:
Various types of computer-based simulated patient cases have been developed and introduced in medical and healthcare education during the last 10-15 years. Most of these have been aiming for learning and training various skills and have been used in preclinical, clinical and graduate education. Today, the common term for these kinds of learning systems is Virtual Patients, or VP for short. Virtual Patient applications have been found to best suit learning and training Clinical Reasoning, which can be described as clinical problem solving or clinical decision making. But such cases can also be used for self-evaluation, assessment and also for other tasks.
There are a number of Virtual Patient systems available, but most of them have common features like interactive illness history taking, physical examination, lab/imaging tests, diagnosis and therapy suggestions. Most systems also have a feedback section where the user automatically may receive information about his/her performance and which tasks that were performed good/less good. A number of these systems exist in different languages and have been implemented in various courses around the world. Many VP systems have been focused on only specific medical areas and course set-ups like surgery, radiology or preclinical physiology, but there are also more generic ones, by means of which the teacher or course director can create and edit his/her own cases. Further on, VPs can be used for not only medical education, but also in nursing, dentistry, physiotherapy and similar programs.
Today, there are many scientific studies published describing increased motivation and engagement of students as well as of comparisons with more traditional learning materials when using VPs. However, few studies have focused on learning outcomes, the use of VPs for assessment and the use of Virtual scenarios and cases for also diagnosing and treatment of (real) patients.
In this presentation, a number of Virtual Patient systems developed by the Virtual Patient lab at Karolinska Institutet in Sweden will be presented, demonstrated and discussed. These include Interactive Simulation of Patients (ISP), Web-based Simulation of Patients (Web-SP) and national Educational program for Dermatology and Venereology (Nudov). Experiences from implementation in different settings, student opinions as well as teachers’ views will be presented. Examples of Virtual patient applications for Assessment will also be shown and discussed, together with relevant literature references. Recommendations regarding implementation strategies, development of cases and methods for international exchange of cases will be discussed.
Finally, a new possible use for virtual cases and scenarios for diagnosing, risk-estimation and rehabilitation of patients and clients within psychiatry and criminal (prison) care will be demonstrated and discussed. This system, Reactions on Display (RoD) is also intended for use in rehabilitation of men sentenced to prison for domestic abuse.
Uno Fors is professor in Medical Educational Simulation at Karolinska Institutet in Sweden as well as professor in IT and Learning at Stockholm University in Sweden and has been leading development and research projects for Virtual patients since more than 25 years.

A. Ryska, I. Tacheci, M. Uhrin (Charles University, Czech Republic)
New possibilities in multidisciplinary clinical education based on virtual clinical cases

Abstract:
Practical classes are the fundamental segment of undergraduate medical education, focused on presentation of wide spectrum of most important symptoms, syndromes or diseases in any medical discipline. One of the important tasks which should be gained during this form of education is also adoption of basic diagnostic and therapeutic algorithms.
However, spectrum of patients available at the moment for clinical examination as well as by time of the courses is limited. This may lead to differences in the quality of each practical class and thus result in differences between individual students. The attempts to standardize spectrum of presented clinical cases can resolve this problem only partially.
One possible solution of this limitation is the simulation of various diseases by information technologies. The presented project is based on a newly developed dynamic database of virtual patients in an outpatient clinic.
After registration to the system, each user obtains login and password warranting an access to virtual doctor's office. The system simulates the real clinical practice as much as possible. It randomly generates a unique set of individual virtual patients (clinical cases) - thus, at the beginning, each participant sees a waiting room full of so far unseen patients seeking his advise and help. The spectrum of diagnoses, number of patients and criteria for completion of the course are defined in advance by the tutor. The system is designed as much flexible, as possible. It can be replenished by virtually unlimited number of patients without any limitation regarding type of disease, clinical specialization, type of diagnostic procedure, etc.
In each virtual patient are generated personal data, history, current complaints, clinical diagnostic findings and results of various tests (laboratory tests, imaging methods, biopsy results, etc.). Clinical history, physical examination results and findings from diagnostic procedure were acquired from charts of real patients. In each individual virtual patient are combined data from several real patients (to prevent possibility of student's bias based on experience from his colleagues, repetition of the same patient, etc). This combination, however, is not entirely random, but is based on highly sophisticated parameters, so that all data (patient's history, complaints, results of clinical examination, etc.) fit together and correspond with the final diagnosis.
Student must suggest the optimal diagnostic algorithm and determine the correct diagnosis for successful completion of the case. During the handling of each patient, student orders (based on patient's history and clinical examination) various diagnostic procedures (including the laboratory tests, wide spectrum of imaging methods, endoscopic examinations, etc.). Clinical findings and results of ancillary examinations are presented not only as text but also as photographs, instructive video sequences, X-ray pictures, virtual histological slides, etc..
Software evaluates how the selected tests contribute to solve the case and find final diagnosis. Each meaningful and rationally chosen method or test is awarded by positive points. In case of unnecessary (or even harmful) diagnostic method is the student awarded by negative points. The total economic cost of used diagnostic methods is calculated (based on costs of these procedures in real healthcare system) too. It is also evaluated, whether the sequence of diagnostic methods was correct or not.
Injury of patient due to the harmful examination, too long, inconvenient or complicated diagnostic approach or economical failure (depletion of the budget) leads to early termination of clinical case (the patient is withdrawn and student is penalized). The case is solved when the student is able to make correct diagnosis based on the WHO International Classification of Diseases.
The system allows detailed analysis of each student's work. The tutor can subsequently objectively assess student's diagnostic skills, diagnostic approach and strong and/or weak aspects leading to the success or failure.
The series of the gastroenterology cases is currently prepared and tested during courses of Internal medicine at the Charles University Medical Faculty in Hradec Králové.
The presented project of virtual case reports can be an optimal addition to face-to-face practical education of clinical subjects at medical faculties. The main advantages are comprehensiveness and diversity of presented cases, possibility to compare students' knowledge, possibility to present optimal, suboptimal and incorrect diagnostic algorithm, to demonstrate less frequent or even very rare symptoms, syndromes and diseases. In addition, each student can prepare assigned case individually at home and later on discuss it with the tutor and colleagues during the classes.
Virtual cases should certainly not replace the contact with patient, as this mode of teaching is essential for each medical student. However, it presents an additional option of broadening the spectrum of possible ways how to study clinical subjects at the medical faculty.

T. Poulton (St George’s University of London, UK)
Virtual Patients: A new generation in Problem-Based Learning?

Abstract:
Virtual patients are interactive computer simulations of real life clinical scenarios for the purpose of medical training education and assessment. They are ideal tools for teaching clinical decision-making.
Problem-based Learning (PBL) is a well-established process in undergraduate medicine, in which students in groups work through a patient scenario, defining the knowledge they require to understand the scenario, exploring diagnoses and subsequent management, and generating learning objectives as they progress. However, as the case unfolds, no matter what the students may reason, or management strategies they select, the case is paper-based, can only unfold in one direction, and is inflexible.
To create a more interactive, decision-making model of our PBL course delivery the eLearning Unit, at St George’s replaced the paper-based with interactive online VPs. As these cases develop, at key points in the case students are presented with options, take decisions, and then explore the consequences of their actions. This process was very successful, and virtual patients have now replaced paper cases at the core of our medical curriculum. In addition, formative assessment VPs were created to provide additional self-directed learning opportunities as companions each week to the relevant PBL cases. eLU also trialled the use of VPs in Virtual Worlds.
This presentation will consider the impact on students and tutors of VPs and associated innovations.

M. Vejrazka, S. Stipek, C. Stuka (Charles University, Czech Republic)
WikiLectures - Hullabaloo in Medical E-Learning

Abstract: WikiLectures (WikiSkripta in the Czech version, www.wikiskripta.eu) were established in 2008; full operation was started in the spring 2009. The concept of openness that belongs to the main characteristics of the project has proven the great viability and astonishing dynamics. After a year and a half, the site contains almost 3000 contributions and about 300 new articles are entered every month. The total number of visits to WikiSkripta exceeded 3.500.000; they are visited from more than 2000 unique users a day.
WikiSkripta represent a connectivistic, Web 2.0 based approach to e-learning. It is complementary to existing, "closed" systems. Authoring a contribution to WikiSkripta is not restricted to teachers; even students may insert, edit or update any text. In this way, students get more involved in the learning process. The role of teacher changes: cooperation between teachers and learners is emphasized. Since students may contribute on writing a textbook for themselves, the expert knowledge of a teacher proving accuracy and defining learning objectives is indispensable.
Authors and readers of WikiSkripta obtain extensive support from editors maintaining the site. Editors are medical students trained for this work. A system of training was established, as well as thorough procedures for controlling the project. Some organisation aspects and tools used by editors will be demonstrated here. Users of WikiSkripta create a community. Social networking and various events organised by this community belong to important motivation factors engaging both students and teachers even more in the education process.
Openness, collaboration and power of students give an unexpected dynamism and efficiency of energy use to this project.

M. Haag (Heilbronn University, Germany)
Virtual Patients for Education, Assessment and Research

Abstract:
Nowadays, virtual patients are becoming increasingly essential for high-quality medical education since there are not enough actual patients available for educational and training purposes. The lack of patients is caused by several reasons: Some diseases are seasonal, patients with severe diseases cannot serve as educational subjects for a large number of medical students and the average stay time of patients in hospitals has decreased over the last years. However, development and curricular integration of virtual patients is challenging and time consuming. This lecture gives an overview on relevant aspects of development and usage of virtual patients for education, assessment and research. It also shows the current state of development as well as perspectives and future challenges.

V. Mihal, J. Potomkova (Palacky University, Czech Republic)
Invited lecture on a casuistic model of evidence-based clinical decision making via blended learning

Abstract:
Learning through experience is an important approach employed by humans to comprehend new problems. Medical practice management is facing a challenge of knowledge discovery from the growing volume of information. Recently, there has been a hot debate about the role of casuistry in the context of evidence-based decision-making. Case-based reasoning (CBR) matches the natural reasoning model similar to that used by physicians: „I have seen a patient like this“, and provides recollection of past cases revlevant to the present case. A general CBR life cycle consists of 4 processes: (1) retrieve the most similar case or cases; (2) reuse the infromation and knowledge in that case; revise the proposed solution; and (4) retain the experience for future problem solving.
Current medical students have grown up with computers and expect learning materials to be available electronically. It is a rapidly expanding field with systems evolving from simple computer storage of learning materials to sophisticated web-based multimedia interactive modules. In medical education, a portion of face-to-face approach seems indispensable which led to introduction of a blended learning design, i.e. development of online modules combined with didactic lectures. These learning opportunities encourage dynamic interplay between learners and teachers with e-learning and may help to obviate some of the potential pitfalls of purely online instruction.
Case stories of real patients supplemented with evidence-based literature reviews may serve a valuable resource to develop hypermedial learning objects. Educational principles must be given priority and include: relevance, reliability, validity of content, clarity of delivery, effective use of time and appropriate assessment.