Provost’s ACIE Award
A Novel Approach to Teaching The
Management of Diabetic Ketoacidosis
Using Virtual Patient Technology
Gary Tabas, MD
University of Pittsburgh
UPMC Shadyside
Background
• Diabetic ketoacidosis (DKA)
– Associated with significant morbidity and
mortality
– Management involves complex decision
making
• LCME ‘educational gap’
– Only a minority of students will encounter a
patient with DKA during ward rotation
Liaison Committee for Medical Education. LCME considers proposed changes in
accreditation standards. December 2006. Available at: http://www.lcme.org/hearing.htm.
Current Educational Methods
• Lecture
• Small group discussion
• PBL (Problem-based Learning)
But management and decision making during
direct patient care are often suboptimal.
New Educational Approach
Simulation would allow students to learn and
practice DKA management skills in a safe
environment
Increasing role of simulation in student
training recognized by
LCME, ACGME
Carnegie Foundation report - Educating
Physicians: A Call for Reform of
Medical School and Residency
“Content of curriculum derived from patients seen”
Project Goals
1. Implement a newly created web-based virtual
patient (VP) simulation to teach the
management of DKA.
2. Pilot test its effectiveness in teaching
DKA-specific clinical decision making.
3. Assess students’ perceptions of the
effectiveness of the DKA VP compared to other
instructional methods.
Virtual Patient Simulation
• Virtual patients are computer-based
simulations of medical cases for education
and assessment
Branched-Narrative VPs
• Multiple pathways through the simulated case
Pathway determined by learner’s management choices
Consequence 1
Choice 1
Consequence 2
Vignette
Consequence
Choice 2
Learning with branched-narrative VPs
• The learner acts as the practitioner who performs
H&P, requests and interprets lab values and makes
management decisions.
• The learner sees the consequences of those
decisions and adjusts management
DKA Branched-Narrative VP
• Diagnose DKA
• Manage fluids, electrolytes, and insulin
• Transition the patient from continuous IV insulin to
subcutaneous insulin
Methods
Program Development
• VP content sources
– Diabetes Care 2006; Kitabchi A.
– In The Clinic; Annals Int Med 2010
– Content review: Endo attending specializing in
DM
• Pretest/posttest:
– Case-based; single best answer; NBME type
aligned with teaching goals
– Content review: Endo attendings and fellows
• Survey: from literature; expert validation
Learning Management system
• VpSim created by the University of Pittsburgh
Laboratory for Educational Technology
• Flash-based visual interface
• Author creates screens and management
choices using a map of nodes and branches.
• Adds patient data to each node.
Better
volume
status
Hypovolemic
DKA patient
Persistent
hypovolemia
Insulin & D5W
Stop insulin
Insulin & saline
Insulin & D5W
Track students' pathways through the case
Track students' pathways through the case
Advantages of VP Simulation
• Exposure to rare patients
• Incorporates adult learning theory:
– Active engagement
– Visualization/rehearsal (neurobiology of learning)
– Adaptive learning (individualized instruction)
– Self-reflection
– Feedback (formative)
Findings To Date
Participants
• 51 Third year medical students
– AIMC
• 84 pharmacy students
– Clinical pharmacology course
• 11 Endocrine fellows
Pretest
VP (path score, time-on-task)
Posttest
Survey
Pre-Posttest Scores
*P = .026
†
P< .001 vs
all posttest
†
Selected Posttest Questions
Scores (%)
†
*
NS
* P = .01
† P<.001
VP Learning Path Score
* P< .001 vs
med students
VP Time-On-Task
* P = .004 vs
other groups
Correlations
Outcomes
*Correlation
P value
VP learning path
score with posttest
score
.31
.0002
Time-On-Task with
VP learning path
score
.21
.013
* Spearman’s ρ
Survey Data
The ability to see and react to the consequences of my
decisions in this module was more effective in teaching me
clinical decision making than with other learning methods
All differences NS
The module was effective in helping me learn how to
adjust therapy in patients with DKA who are not
responding appropriately
*
* P = .02 vs
Med students
The module improved my confidence in managing DKA.
*
* P = .01 vs other
groups
The module was of high educational value
Summary
• It is feasible to create a interactive branchednarrative VP to teach the management of a
complex medical illness
• One way to fill an educational gap
• Effectiveness was significant as evidenced by
pre-posttest score improvement
• Students felt that the VP was effective in
teaching management of DKA and preferred
the VP over other teaching methods
Limitations
•
•
•
•
•
•
Expensive, time consuming
Expertise
Pilot study
One case
Two schools but in one institution
No patient outcomes
Future Research
Compare effectiveness of branched-narrative VP
to traditional VP with only one learning path
Questions?
Funding: University of Pittsburgh Provost’s
Innovations in Education Award
Acknowledgements:
Harsha Rao
Mary Korytowski
Neil Benedict
Mike Elnicki
Dario Torre
JB McGee
Laboratory for Educational Technology
The problem
Insufficient
insulin
GLU
~16
∆
~15
~200
HCO3
2 AM
4 AM
6 AM
8 AM
10 AM
What do we know about the
effectiveness of web-based education?
• Superior to no intervention
• Probably equal to non-internet education for
knowledge gain
• Superior to non-internet education for
learning efficiency
– (knowledge gained per time spent)
• Superior for learning satisfaction
Cook