Abstract
Medical education technology initiatives can be used to prepare osteopathic medical students for modern primary care practice and to provide students with training to serve vulnerable populations. Over academic years 2014 through 2017, the authors designed and implemented 26 case studies using patient simulations through a virtual community health center (CHC). First-year students, who were preparing for clinical training in CHCs, and second-year students, who were training in CHCs, completed the simulation case studies, gaining practice in clinical reasoning, Health Systems Science, and applied osteopathic principles and practice. This article explains the project, illustrates an alignment with Health Systems Science and osteopathic competencies, and highlights findings from previous research studies.
Modern osteopathic medical training must prepare trainees for practice environments in which medical science, technology, and delivery systems are constantly evolving. The 21st century health care professional must be able to work with interprofessional teams; use health technology and data; communicate effectively; focus on patient-centered, preventive, osteopathic primary care; work with community members and institutions; integrate primary care and public health; and adapt with resilience. Thus, medical education must likewise evolve to meet these needs.
Whereas traditional medical education focuses on basic science and clinical science, Health Systems Science (HSS) education has been promoted by the American Medical Association through the work of the Accelerating Change in Medical Education consortium.
1 Described as the third pillar of undergraduate medical education, HSS provides “new physicians a broad view of the societal influences and administrative challenges that sometimes complicate patient care.”
1 Although it continues to evolve, the current core domains of HSS include health care structure and process; health care policy, economics, and management; clinical informatics/health information technology; population health; value-based care; and health system improvement.
1 Medical trainees who achieve competency in HSS will be able to effectively translate and apply both clinical science and basic science in the ever-evolving complex health care system. These providers will be able to address and make a positive impact on patients’ health at the individual, community, and population level.
Additionally, community-oriented primary care (COPC)
2 is a continuous process by which primary health care is provided to a defined community on the basis of its health needs by the planned integration of public health with primary care.
3 New osteopathic curricula provide methods to teach students elements of public health and focus on addressing the social determinants of health. Principles of COPC provide a relevant and pragmatic framework that allows health systems to work toward achieving the quadruple aim
4 of decreasing workforce burnout, improving population health, increasing patient satisfaction, and reducing per-capita health care spending. To deliver high-quality COPC, providers must apply HSS with regard to navigating health care structure and process, interpreting clinical informatics, tracking population health, optimizing value-based care, and improving health care systems.
At A.T. Still University, School of Osteopathic Medicine in Arizona (ATSU-SOMA), a primary focus is to select, mentor, and train primary care physicians who are committed to working in community health centers (CHCs) and other areas with health care disparities. During their first year, osteopathic medical students form learning teams of 10 to 12 students. At the beginning of the second year, these teams travel to an affiliated CHC, where they spend years 2 through 4 in contextual learning environments that incorporate HSS and important elements of service learning—an “embedded, distributed model.”
5,6 Given the need for our students to gain clinical skills and familiarity in practicing in the CHC environments, we developed 26 virtual patient simulation (VPS) case studies set in the Envision CHC, or the Virtual Community Health Center (VCHC). Health Systems Science and COPC were both underlying themes in the development of these cases studies, and this strategy has provided osteopathic medical students, who are embedded in CHCs across the country, deliberate practice with contextualized HSS competencies.
The VCHC project emphasizes the new osteopathic medical education paradigm by moving osteopathic medicine into the forefront of primary care instruction. Case studies in the VCHC align with osteopathic core competencies outlined by the American Association of Colleges of Osteopathic Medicine (
Figure 1). Medical students practice osteopathic diagnostic and treatment skills, as well as have osteopathic considerations integrated in a wide variety of clinical cases beginning in the first year.
In this article, we describe the virtual learning environment and implementation of the VCHC. Furthermore, we map VCHC cases to the elements of HSS and osteopathic principles and practice (OPP). We reference earlier evaluation studies to enhance the description and provide examples of ongoing analyses for institutions that may wish to incorporate this or similar programs into their curricula.
Given ATSU-SOMA's emphasis on community health and the need to foster skills associated with HSS and COPC, the aim of the VCHC project was the acculturation of medical students and other health professions trainees toward osteopathic primary care for community clinics.
7 The original impetus for developing the VCHC was to develop situated,
8 cognitively engaging
9 VPS exercises. Before this project, medical student case study practice involved noninteractive, Microsoft PowerPoint–format case studies. Most fictitious patients were anonymous, white, and male. Clinical cases were not situated in community clinics and thus did not reflect social determinants of health in medically underserved populations. Faculty felt osteopathic medical students should practice humanizing care skills, such as learning proper use of patient names, understanding social determinants of health, developing fluency caring for patients from all ethnic backgrounds, and avoiding objectification or bias toward patients.
10 In developing a realistic patient panel for the VCHC, the authors reviewed CHC patient demographic statistics.
Virtual patient simulation has emerged as an important medium of medical education, filling gaps within rotations, distance learning, residency, and traditional case practice.
11 A growing body of research highlights their utility as safe learning contexts to practice patient care before or as a supplement to actual patient encounters.
12,13 Compared with traditional case formats such as PowerPoint, VPS formats offer a variety of educational advantages, fostering clinical decision-making, providing standard feedback, and allowing each student to actively participate.
7 The millennial generation of students has been influenced by video games, which often have dramatic story elements and virtual worlds.
14 Learners from this generation and the next (Generation Z or post-millennials) bring a sophisticated technology skill set and sense of collaboration, having been brought up with new media and gamification.
15 We hoped realistic cases set within a virtual world would make case studies more compelling.
14
We implemented the VCHC cases (
Table 1) primarily within first- and second-year osteopathic medical school courses during required case practice. In the current flipped lesson format,
16 learners access the cases online through the platform DecisionSim approximately once per month before small group case practice. Students then discuss the cases and the various social, economic, and policy implications in class during debrief sessions with their peers and faculty tutors.
With each case, photographs of standardized patients are used to provide visual points of reference (
Figure 2). Students learn to care for patients by managing each part of the patient encounter:
Following a self-directed learning approach,
17 osteopathic medical students assume the provider role, evaluate a patient, make meaningful choices, and explore the consequences of these choices. This approach allows for situated cognition, as well as legitimate peripheral participation,
8 a process whereby students are initiated into the professional role of physician in a peripheral (safe and risk-free) environment. Student learning is scaffolded via the feedback provided in each case module, and a debrief exercise that follows the case study allows for personal and group reflection.
The VCHC allows first- and second-year osteopathic medical students to experience health care systems linked to communities, as well as interprofessional interactions linked to specific patient encounters.
18 For example, students might inventory social determinants of health for a given patient and discuss patient-centered care, the needs of the family, osteopathic manipulative treatment (OMT) considerations, or community health implications. The results from student case debrief sessions have been reported in prior publications.
7,18
The results of this innovation have been published in 2 prior mixed-methods studies.
18,19 The evaluation (pilot) phase of the project demonstrated feasibility of the learning model and allowed researchers to work out methods for distributing the cases, tracking learning analytics, and video recording implementation sessions. We measured the value of this learning platform in terms of engagement, clinical reasoning, awareness of COPC, and OPP.
In a 2016 study,
18 researchers investigated whether the VCHC was cognitively engaging and fostered teamwork and participation. Triangulation of findings between the 4 data sources indicated that VCHC interactive cases were engaging in 3 dimensions: flow, interest, and relevance. In general, students enjoyed the activities and were absorbed in the clinical encounters. The issues with the cases, as expressed by students and tutors, were excessive text, time constraints, requested refinements in terms of alignment of case content to large group lectures, and the desire for students to practice the cases at home.
The virtual cases provided deliberate practice with clinical reasoning, COPC principles, and osteopathic diagnosis and treatment. In a 2016 study,
7 student clinical reasoning and awareness of COPC were measured using pre- and posttest data, case analytics, student responses to case debriefs, and tutor feedback for 8 VCHC cases. For a cohort of 93 first-year students, significant improvement in clinical reasoning was found.
7 Student teams of 3 to 4 learners worked through 8 cases, and teams received a mean overall score of 74.7 out of 100 possible points. Individual scores improved between pre- and posttests, with a mean gain of 15.4 points (
P<.001).
7 Case debriefs allowed students the opportunity to discuss patient care, family-oriented care, and treatment options, including OMT. Tutors reported that students were absorbed in the case studies, an indication of flow and situational cognitive engagement. This finding was corroborated by a separate study that relied on photographic evidence of student affect and participation.
18 Several issues surfaced during this referenced study. Due to time constraints within the small group sessions, it was difficult to require multiple-choice assessments for each case that had enough test items and that were aligned to course examinations. The case scoring system needed refinement, and the cases had too many branching pathways.
Elements of HSS and COPC were intentionally integrated into each VCHC case module.
1 Core domains of HSS include the following: health care structures and process; health care policy, economics, and management; clinical informatics/health information technology; population health; value-based care; and health system improvement. In addition, VCHC case modules address many of the HSS crosscutting domains, such as leadership and change agency, teamwork and interprofessional education, evidence-based medicine and practice, professionalism, ethics, and scholarship.
1 Crosscutting domains transcend the core domains and relate to direct patient care competencies. The COPC domains included specific primary care skills: family-centered care; patient-centered care; patient social determinants of health and extended history; diagnostic reasoning and safety; health care team dynamics; warm handoffs; cost-effective treatment and payment options; respectful, humanistic, and compassionate interactions; electronic health records; osteopathic manipulative medicine (OMM) and OMT; evidence-based basic science tutorials; and community-oriented solutions.
2
To determine the saturation level of each competency domain for each case, an independent consultant with significant Health Systems Science expertise conducted a post-hoc analysis of the alignment of curricular content of the 26 VCHC cases with core elements of HSS and OPP. This analysis was exempted by the ATSU Institutional Review Board.
First, the HSS expert defined categories, using the Skochelak et al textbook,
1 and formatted them into a Microsoft Excel workbook. Second, within the COPC category, a competency subcategory of “OMM and OMT” was introduced. Cases including all osteopathic components (ie, relevant history, osteopathic structural examination, an osteopathic case consultation, and OMT videos) were coded as meeting the OMM and OMT core element. Third, the HSS expert progressed through each VCHC case study in a chronological fashion, from case 1 through case 26. For each case, she listed the case page number and corresponding title of the case page and coded the pertinent HSS core domains and crosscutting domains for the given page. Fourth, for case pages with multiple decision possibilities that could bring about varying results and virtual patient outcomes, she selected each decision point and followed through the consequences of each clinical decision to record all possible corresponding HSS core and crosscutting domains for each decision possibility. The HSS expert repeated this process for every page and for all 26 cases. Finally, the completed crosswalk was reviewed by team members (L.M., J.H.L., T.B., D.M.H., and F.N.S.). This team ensured domain agreement with the categories (and subthemes for each category) listed by Skochelak et al.
1
Findings from this analysis are summarized in
Table 2, documenting the breadth of HSS and COPC covered by the VPS cases. Results suggest the VCHC cases addressed nearly all of the HSS core domains except “Health Systems Improvement” and “Scholarship.” Thus, through the VCHC training program, trainees practiced a broad array of HHS topics at the level of first- and second-year osteopathic medical students. All of the crosscutting domains (other than scholarship) were integrated. Furthermore, the VCHC provided many opportunities for the risk-free practice of COPC-related skills.
In terms of alignment with OMM and OMT, as reported in
Table 2 under the subcategory “Community-Oriented Primary Care,” 25 of the 26 VCHC case studies integrated osteopathic considerations, including relevant history, osteopathic structural examination, an osteopathic case consultation, and OMT videos.
The innovation we describe in the present report reflects our efforts from 2014 through 2017 to develop a new training platform suitable for first- and second-year osteopathic medical students. The journey of developing the library of 26 virtual cases has been time consuming but enriching. In the current phase of the project, it appears that the VCHC cases provide deliberate practice with HSS and OPP competencies. The HSS domains of scholarship and health systems improvement were not addressed; these facets of HSS were not easy to integrate into VPS.
The VCHC was developed for students bound for community health care environments. While elements and formats of this library of virtual cases may be of interest to other osteopathic medical schools, some features, such as the clinical presentation model for deliberate practice with clinical reasoning, might not translate to other training contexts. Although faculty members have addressed issues that surfaced in earlier evaluation studies (excessive text, short multiple-choice quizzes, individual case practice at home before small group), there are new challenges this year, including the following:
Integrating these activities within the existing small group case curriculum required several years of building trust and strong communication with the team of small-group tutors. Continuous training of the small-group tutors facilitated the uptake and standardization of this new instructional intervention.
To our knowledge, the VCHC cases are among the first virtual patient simulations to integrate the full spectrum of osteopathic considerations, including osteopathic structural examinations and OMT. Future directions include developing more cases for interprofessional education, resident training, continuing medical education, public health, and competency-based education in distance-training environments.
In response to medical practice transformation, medical schools are striving to introduce HSS curricula and service learning experiences. In designing this medical education innovation, we sought to design engaging case studies integrating HSS competencies in a virtual world. An analysis of competencies and case content indicates that VCHC cases successfully integrated most HSS competencies and OPP into clinical cases. Although the project has been time consuming and challenging, it has been highly rewarding in terms of achieving an engaging method for providing practice with HSS and OPP competencies for osteopathic medical students.
We acknowledge Earla White, PhD, MEd, RHIA, for her analysis of the alignment of curricular content of the 26 VCHC cases with core elements of HSS and OPP.