A Novel Approach to Teaching The Management of Diabetic Ketoacidosis

Using Virtual Patient Technology

Gary Tabas, MDUniversity of Pittsburgh

UPMC Shadyside

Provost’s ACIE Award

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 ApproachSimulation 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 casePathway determined by learner’s management choices

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.

Hypovolemic DKA patient

Bettervolume status

saline

D5W

Persistenthypovolemia

oral fluids

Insulin & D5W

Insulin & saline

Stop insulin

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

NS

*

†

* P = .01 † P<.001

Scores (%)

VP Learning Path Score

* P< .001 vs med students

VP Time-On-Task

* P = .004 vs other groups

CorrelationsOutcomes *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 branched-narrative 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 AwardAcknowledgements:Harsha RaoMary KorytowskiNeil BenedictMike ElnickiDario TorreJB McGeeLaboratory for Educational Technology

The problem

GLU

∆

HCO3

2 AM 4 AM 6 AM 8 AM 10 AM

Insufficient insulin

~200

~15

~16

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