Using virtual standardized patients to accurately assess information gathering skills in medical students.

Introduction: Practicing a medical history using standardized patients is an essential component of medical school curricula. Recent advances in technology now allow for newer approaches for practicing and assessing communication skills. We describe herein a virtual standardized patient (VSP) system that allows students to practice their history taking skills and receive immediate feedback. Methods: Our VSPs consist of artificially intelligent, emotionally responsive 3D characters which communicate with students using natural language. The system categorizes the input questions according to specific domains and summarizes the encounter. Automated assessment by the computer was compared to manual assessment by trained raters to assess accuracy of the grading system. Results: Twenty dialogs chosen randomly from 102 total encounters were analyzed by three human and one computer rater. Overall scores calculated by the computer were not different than those provided by the human raters, and overall accuracy of the computer system was 87%, compared with 90% for human raters. Inter-rater reliability was high across 19 of 21 categories. Conclusions: We have developed a virtual standardized patient system that can understand, respond, categorize, and assess student performance in gathering information during a typical medical history, thus enabling students to practice their history-taking skills and receive immediate feedback.

Diagnosis and management of red eye in primary care.

Red eye is the cardinal sign of ocular inflammation. The condition is usually benign and can be managed by primary care physicians. Conjunctivitis is the most common cause of red eye. Other common causes include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. Signs and symptoms of red eye include eye discharge, redness, pain, photophobia, itching, and visual changes. Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare. Because there is no specific diagnostic test to differentiate viral from bacterial conjunctivitis, most cases are treated using broad-spectrum antibiotics. Allergies or irritants also may cause conjunctivitis. The cause of red eye can be diagnosed through a detailed patient history and careful eye examination, and treatment is based on the underlying etiology. Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye. Referral is necessary when severe pain is not relieved with topical anesthetics; topical steroids are needed; or the patient has vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent infections.

Developing a Conversational Virtual Standardized Patient to Enable Students to Practice History-Taking Skills.

INTRODUCTION: Although traditional virtual patient simulations are designed to teach and assess clinical reasoning skills, few employ conversational dialogue with the patients. The virtual standardized patients (VSPs) described herein represent standardized patients that students interview using natural language. Students take histories and develop differential diagnoses of the VSPs as much as they would with standardized or actual patients. The student-VSP interactions are recorded, creating a comprehensive record of questions and the order in which they were asked, which can be analyzed to assess information-gathering skills. Students document the encounter in an electronic medical record created for the VSPs. METHODS: The VSP was developed by integrating a dialogue management system (ChatScript) with emotionally responsive 3D characters created in a high-fidelity game engine (Unity). The system was tested with medical students at the Ohio State University College of Medicine. Students are able to take a history of a VSP, develop a differential diagnosis, and document the encounter in the electronic medical record. RESULTS: Accuracy of the VSP responses ranged from 79% to 86%, depending on the complexity of the case, type of history obtained, and skill of the student. Students were able to accurately develop an appropriate differential diagnosis on the basis of the information provided by the patient during the encounter. CONCLUSIONS: The VSP enables students to practice their history-taking skills before encounters with standardized or actual patients. Future developments will focus on creating an assessment module that will automatically analyze VSP sessions and provide immediate student feedback.

A comparison of family medicine and internal medicine experiences in a combined clerkship.

BACKGROUND: Learning experiences during the medical school clinical rotation are largely shaped by patient contacts in a variety of clinical settings. For this reason, it is important to learn as much as possible about whether learning goals are being met. The patient encounter log has been used as a program evaluation tool to track students' clinical experiences. METHODS: In the present study, we used a scannable pencil and paper form to compare clinical and demographic data from two primary care experiences in a multidisciplinary clerkship. Students manually recorded the encounter date, patient age and gender, the students' level of involvement with the patient, and involvement with procedures. Up to four diagnoses relevant to the encounter were also recorded. To document the clinical content of the encounters, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9- CM) codes were used. RESULTS: Differences in patient encounters were found in five of the most frequently logged ICD-9-CM categories and also the presence of multiple diagnostic categories. Fewer family medicine encounters could be categorized as observational than general internal medicine encounters, and students on the family medicine month conducted physical examinations more frequently. Lower patient age was recorded for family medicine patients seen. Patient gender was balanced and comparable for the two specialties. The majority of the most frequently logged ICD-9-CM categories were strikingly similar. The range of diagnoses logged was identical. Students also documented similar opportunities for first contact with patients, doing patient histories, and the lack of exposure to procedures. CONCLUSIONS: Ambulatory family medicine and internal medicine experiences can be both reinforcing and complementary, resulting in a more complete view of primary care. Common exposures in some diagnoses, ie, hypertension, can illuminate subtle differences in how family physicians manage patients in contrast to general internists. Students benefit from "hearing it again" but also from seeing that different approaches can lead to beneficial effects for patients. Other diagnoses that students experience in family practice offices that differ from their internal medicine rotation and vice versa ensure that students experience both the breadth and depth of primary care.

Medical Student Summer Externship Program: Increasing the Number Matching in Family Practice.

BACKGROUND AND OBJECTIVES: The number of US allopathic medical school graduates choosing a residency in family medicine has fallen from 13.4% in 1999 to 10.5% in 2002. Concern about declining numbers has led to the development of programs to provide medical students exposure to family medicine outside the clerkship. This paper reports on the development and longitudinal achievements of a clinical summer externship program 1993 to 1999. METHODS: The program description, practice settings, students' experiences, and department commitment are described. The purpose of this prospective study is to determine the percentage of family medicine summer externship participants (n=115) who match into family medicine. RESULTS: During the six years studied, 49 (43.4%) of the participants matched into family medicine. Program participants viewed the program favorably, mean = 5.82 out of 6. CONCLUSIONS: The Ohio State University Department of Family Medicine Medical Student Summer Externship Program demonstrates an effective educational experience that can increase and/or attain the proportion of students going into family medicine at the time of graduation.

Management of Crohn's disease--a practical approach.

Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract that affects up to 480,000 persons in the United States. Symptoms include abdominal pain, diarrhea, fever, malaise, and arthralgias, and cause considerable morbidity. Speculation about genetic, environmental, dietary, infectious, and immunologic etiologies has led to treatment modalities directed at each theoretic cause, but therapy guidelines are determined by the severity of disease. Use of salicylates and/or antibiotics can be effective in mild to moderate disease, while steroids are the accepted therapy for more severe active disease. Azathioprine and other immunosuppresant drugs can be used as adjunctive therapy for active Crohn's disease and may help to maintain remission. Infliximab, an antibody to human tumor necrosis factor alpha, has proved successful in the treatment of severe refractory disease and generally causes only mild side effects. Therapy for Crohn's disease must involve treating comorbid conditions to improve the quality of life of patients.