E-learning for everyone

Virtual patients expose students and physicians to a wide range of clinical scenarios.


A 33-year-old man arrives in the ED with radiating chest pain, nausea and vomiting. He is obese, borderline hypertensive, smokes and has untreated hyperlipidemia, but has no family history of heart disease. An exam, lab tests and electrocardiogram reveal nothing abnormal, and his pain resolves. What should the doctor do?

This scenario isn't playing out in a real ED. It's a virtual case unfolding on a computer screen. Around the country, medical students, residents and seasoned physicians are turning to e-learning to immerse themselves in new information, reinforce things they learned on a clinical rotation or brush up on a subject they learned years ago.

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E-learning programs can range from traditional classroom-type material to PowerPoint presentations posted online to video clips of virtual patients. Some Web-based curriculum is made available for free; some is sold by companies in the e-curriculum business. The Association of American Medical Colleges (AAMC), for example, has an online service called MedEdPORTAL, which offers teaching resources (both electronic and paper-based) that are peer-reviewed and available free of charge.

“The chief advantage [of e-curriculum] is the ability for learners to participate regardless of their location in time or space,” said David A. Cook, ACP Member, chair of the medical education research group of the Mayo Clinic College of Medicine in Rochester, Minn., where over three years, internal medicine and family medicine residents complete 12 online modules on various topics, including diabetes, cardiovascular disease and chronic obstructive pulmonary disease.

“They can be working from home, a clinic, or other outlying site. They can do the work when they want to do it,” Dr. Cook said. “They can work on it if they have a patient cancel; they can work on it at two in the morning when they are free.”

E-curriculum for students

With patients in and out of the hospital so quickly and most care for chronic conditions being provided outside of the hospital, it can be tough for medical students and residents on rotations to encounter a range of patients and conditions. They might not, for instance, encounter a patient with asthma during their internal medicine hospital rotation, but they could meet such a patient in a Web-based course.

Two screenshots of a virtual patient with chest pain courtesy of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston
Two screenshots of a virtual patient with chest pain, courtesy of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston.

Grace Huang, MD, a hospitalist at Beth Israel Deaconess Medical Center in Boston and director of assessment at the Carl J. Shapiro Institute for Education and Research at Harvard Medical School and BIDMC, has helped develop 18 virtual patients, including the man who comes to the ED with chest pain. The doctor must decide whether to admit the patient for further observation, or prescribe proton-pump inhibitors and send him home. If the patient is discharged, he ends up dying of a massive myocardial infarction and the case concludes with a call from the family's lawyer.

“That's meant to be somewhat humorous,” Dr. Huang said. “But the point is that your actions in real life have consequences on patients.”

Medical students tend to be enthused about virtual patients, said Dr. Huang, but the current technology has limits.

“When students interview a patient and type in questions, the computer may not understand,” said Dr. Huang, who consults for the AAMC on the use of virtual patients and MedEdPORTAL. In the future, she said, technology should improve to make communication between the student and the computer more realistic. Some programs already allow several people to care for a virtual patient at once, replicating the give and take that often happens in the real world of medicine.

E-resources for physicians

Jason Stein, ACP Member, a hospitalist at Emory University in Atlanta, is the managing editor of a series of Web-based quality-improvement resource rooms sponsored by the Society of Hospital Medicine. The resource rooms offer help on topics such as venous thromboembolism, glycemic control, stroke, heart failure and care transitions for older patients. The e-materials are designed to help hospitals put quality improvement programs in place, Dr. Stein said, He estimates that at least 25 different medical centers as well as the Veterans Administration have used the downloadable VTE prevention guide.

“The guide puts forward a standardized approach derived from the successful experiences of its authors,” said Dr. Stein, who co-chairs the Emory Department of Medicine's quality program. “Doing it the same every time is the first critical step on the road to doing it right every time. The Web lets us disseminate a standardized approach. Interactive discussion communities provide a forum for suggestions about how to improve on that standard.”

Paula Podrazik, MD, a geriatrician, collaborated with fellow geriatricians, hospitalists and internists at the University of Chicago to create a faculty development program called CHAMP, or Curriculum for the Hospitalized Aging Medical Patient, which has a Web-based component. The program, which was funded by an educational grant from the Donald W. Reynolds Foundation, is aimed at hospitalists, internists and geriatricians who teach in the inpatient setting.

CHAMP has sections on how to identify frail elderly, prevent hazards of hospitalization, provide palliative care and address end-of-life issues, and improve transitions of care. The program includes materials aimed at teaching at the bedside, as well as triggers to help faculty recognize teaching opportunities.

“The need for an increased number of health care providers well-versed in care of the elderly patient can only be underscored by the need for those to teach this medical care. We have to be able to get our attendings to be able to recognize the opportunities to teach,” said Dr. Podrazik, who hopes to take her CHAMP curriculum beyond the University of Chicago. “An e-learning component to exporting CHAMP is crucial.”

Back to the future

Experts say online learning will continue to increase, though it will never replace learning at the bedside or under the tutelage of an accomplished instructor. And there's nothing magical about an e-course: Just as there are bad speakers, hard-to-follow PowerPoint presentations and tedious lectures involving an overhead projector, e-courses can also be ineffective.

“These courses are good for teaching medical knowledge,” said Stephen Sisson, ACP Member, associate program director for the Osler Medical Residency Training Program at Johns Hopkins' division of general internal medicine in Baltimore, who developed an e-curriculum used by 84 U.S. residency programs.

E-courses fall short on teaching skills or attitude, he noted. For instance, students or residents can watch a video clip on how to do a knee examination, but it isn't until they actually manipulate a knee that they get a feel for it. Likewise, they may not buy into the importance of considering depression when evaluating a patient unless they see an instructor taking time to do so.

“There's an advantage to role modeling and behavioral teaching,” said Dr. Sisson. “If I'm very enthusiastic about treating a patient with depression, my resident can get excited because I'm excited. It's hard to capture that attitude online.”

Research is needed on how best to integrate e-curriculum into learning, said Dr. Cook. The question isn't whether to use it, but rather when and how. Researchers and educators also need to develop objective measures to assess whether an e-user is learning.

“E-learning has to do more than just provide information,” Dr. Cook said. “The learner needs to be mentally involved. . . . Just because they're clicking a mouse doesn't mean they're engaged in learning.”

Susan FitzGerald is a freelance writer in Philadelphia.

Web exclusive

Click here to see the introductory video clip of a virtual patient with chest pain. The clip is courtesy of the Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. (QuickTime required; click here to download this free software.)

For more information

For more information on e-curriculum and online learning, visit the following Web sites.

  • The Carl J. Shapiro Institute for Education and Research. The Shapiro Institute at Harvard University runs the Virtual Patient Project, which uses multimedia teaching cases to help medical students and post-graduate trainees learn about common illnesses. Click on Multimedia Programs in the site's left-hand navigation bar to learn more.
  • CHAMP. Developed at the University of Chicago, CHAMP, or Curriculum for the Hospitalized Aging Patient, is aimed at hospitalists, internists and geriatricians who teach in the inpatient setting.
  • MedEdPORTAL. An online service from the Association of American Medical Colleges, MedEdPORTAL offers free peer-reviewed teaching resources, both electronic and paper-based.
  • Society of Hospital Medicine. SHM's online resource rooms offer help on such topics as venous thromboembolism, glycemic control, stroke, heart failure and care transitions for older patients.