The use of virtual patients for developing the evidence informed, shared decision making of clinicians

Background Shared decision-making (SDM) involves a patient and a health professional sharing information to arrive at a decision that aligns with both the best available evidence and the patient’s preferences. Research shows that SDM is not occurring in practice to the extent that it ought to. SDM is proposed as a skill of communication which means that it can be learnt and developed. Virtual Patients (VPs) are computer programs that simulate real-life clinical scenarios; learners take on the role of a health professional to interact with a patient and make decisions. VPs may provide a way for students and professionals to practice SDM. Very few VPs published in the literature focus on SDM or related concepts. Aim To design and evaluate a VP for developing the shared decision-making skills of undergraduate medical and pharmacy students, and General Practice Registrars (GPRs). Method A multi-step design process incorporating patient involvement was followed to create the VP. Mixed-method evaluations of the VP utilising pre- and post-questionnaires and semi-structured interviews were conducted at a series of workshops. The qualitative questionnaire data was analysed using content analysis. Descriptive statistics were used for the majority of the quantitative data; one question was analysed using a Wilcoxon rank test. The interview data was analysed by data-driven thematic analysis. Results The VP was found by workshop participants to be both enjoyable and easy to use. The multiple-choice system of interaction provided useful prompts to the participants as to which words and phrases they could use. In future, an extended feedback activity may be required but the optimal composition of this is unclear. For the pharmacy and medical student evaluations, there was a statistically significant change in the rank position of “Respecting patient choices” when comparing pre- and post-VP (p=0.026 and p=0.038 respectively); in both cases, the median rank changed from 2nd to 1st. The modal suggestion for each evaluation was that it was “Likely” there would be changes in the participants’ practice as a result of the VP; the suggested changes were broadly in line with the aims of the VP. Conclusions The VP was well accepted by the majority of the participants in all of the evaluations. The multiple-choice system had some particular advantages for less experienced consulters but its place with those more experienced is unclear. The VP resulted in positive changes in both the participants reported priorities within a consultation and suggested changes in their practice

Shared Decision-Making With a Virtual Patient in Medical Education: Mixed Methods Evaluation Study.

BACKGROUND: Shared decision-making (SDM) is a process in which clinicians and patients work together to select tests, treatments, management, or support packages based on clinical evidence and the patient's informed preferences. Similar to any skill, SDM requires practice to improve. Virtual patients (VPs) are simulations that allow one to practice a variety of clinical skills, including communication. VPs can be used to help professionals and students practice communication skills required to engage in SDM; however, this specific focus has not received much attention within the literature. A multiple-choice VP was developed to allow students the opportunity to practice SDM. To interact with the VP, users chose what they wanted to say to the VP by choosing from multiple predefined options, rather than typing in what they wanted to say. OBJECTIVE: This study aims to evaluate a VP workshop for medical students aimed at developing the communication skills required for SDM. METHODS: Preintervention and postintervention questionnaires were administered, followed by semistructured interviews. The questionnaires provided cohort-level data on the participants' views of the VP and helped to inform the interview guide; the interviews were used to explore some of the data from the questionnaire in more depth, including the participants' experience of using the VP. RESULTS: The interviews and questionnaires suggested that the VP was enjoyable and easy to use. When the participants were asked to rank their priorities in both pre- and post-VP consultations, there was a change in the rank position of respecting patient choices, with the median rank changing from second to first. Owing to the small sample size, this was not analyzed for statistical significance. The VP allowed the participants to explore a consultation in a way that they could not with simulated or real patients, which may be part of the reason that the VP was suggested as a useful intervention for bridging from the early, theory-focused years of the curriculum to the more patient-focused ones later. CONCLUSIONS: The VP was well accepted by the participants. The multiple-choice system of interaction was reported to be both useful and restrictive. Future work should look at further developing the mode of interaction and explore whether the VP results in any changes in observed behavior or practice

Bringing ethical dilemmas to life; the use of drama teaching in healthcare education

Context and objectivesEmpathy is an important element that underpins a health professional’s ability to handle ethical dilemmas involving patients, with a focus on providing person-centred care. The aim of this project was to evaluate the use of an innovative teaching approach involving drama to help students experience and understand the emotional aspects of ethical dilemmas.MethodsA pragmatic approach was applied whereby a focus group was undertaken to gain views of pharmacy students, and a brief questionnaire was emailed to medical students who attended the session. The focus group was transcribed verbatim and analysed thematically using the Framework Approach. The questionnaire data was analysed descriptively.ResultsThirty-five pharmacy students and 10 medical students attended a teaching session. Discussion from the focus group (n = 4) centred around four main themes: general views of the session; benefits to students; drawbacks to the session; potential improvements. Students reported many benefits, including evocation of a strong empathetic response, widening perspectives, possibly building confidence, and having the opportunity to observe confrontation. Data from the questionnaire (n=4) showed all students enjoyed the session. Both groups reported that the session should be continued, and widened to include more disciplines. Suggestions for potential improvements included providing a range of scenarios, linking the session to assessment and providing transport to the theatre.ConclusionThis evaluation has found a novel teaching method, in collaboration with the New Vic Theatre, to be an effective and engaging way to help develop empathy whilst addressing ethical dilemmas in a safe environment

A realist review of medication optimisation of community dwelling service users with serious mental illness

BACKGROUND: Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE: Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS: A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS: Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS: Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER: CRD42021280980

Training healthcare professionals to be ready for practice in an era of social distancing: A realist evaluation

Background Programme changes due to the COVID-19 pandemic have impacted variably on preparation for practice of healthcare professional students. Explanations for such variability in outcomes between institutions and healthcare professions have yet to be explored. The aim of our study was to understand what clinical learning, whilst under socially distanced restrictions, worked and why (or why not). Methods We conducted a realist evaluation of the undergraduate healthcare programmes at one UK university in 2020-21. The initial programme theories to be tested in this study were derived from discussions with programme leads about the changes they implemented due to the pandemic. Study participants were students and teaching faculty. Online interview transcripts were coded, identifying why the interventions in the programme had worked or not. This resulted in a set of ‘context-mechanism-outcome’ (CMO) statements about each intervention. The initial programme theories were refined as a result. Results and discussion 29 students and 22 faculty members participated. 18 CMO configurations were identified relating to clinical skills learning and 25 relating to clinical placements. Clinical skills learning was successful whether in person, remote or hybrid if it followed the steps of: demonstration – explanation – mental rehearsal – attempt with feedback. Where it didn’t work there was usually a lack of observation and corrective feedback. Placements were generally highly valued despite gaps in experience. Being useful on placements was felt to be good preparation for practice. Participant explanations from junior students about the value of various modes of induction to clinical workplace activity may also be relevant post-pandemic

Hot Spot or Not: A Comparison of Spatial Statistical Methods to Predict Prospective Malaria Infections.

Within affected communities, Plasmodium falciparum infections may be skewed in distribution such that single or small clusters of households consistently harbour a disproportionate number of infected individuals throughout the year. Identifying these hotspots of malaria transmission would permit targeting of interventions and a more rapid reduction in malaria burden across the whole community. This study set out to compare different statistical methods of hotspot detection (SaTScan, kernel smoothing, weighted local prevalence) using different indicators (PCR positivity, AMA-1 and MSP-1 antibodies) for prediction of infection the following year. Two full surveys of four villages in Mwanza, Tanzania were completed over consecutive years, 2010-2011. In both surveys, infection was assessed using nested polymerase chain reaction (nPCR). In addition in 2010, serologic markers (AMA-1 and MSP-119 antibodies) of exposure were assessed. Baseline clustering of infection and serological markers were assessed using three geospatial methods: spatial scan statistics, kernel analysis and weighted local prevalence analysis. Methods were compared in their ability to predict infection in the second year of the study using random effects logistic regression models, and comparisons of the area under the receiver operating curve (AUC) for each model. Sensitivity analysis was conducted to explore the effect of varying radius size for the kernel and weighted local prevalence methods and maximum population size for the spatial scan statistic. Guided by AUC values, the kernel method and spatial scan statistics appeared to be more predictive of infection in the following year. Hotspots of PCR-detected infection and seropositivity to AMA-1 were predictive of subsequent infection. For the kernel method, a 1 km window was optimal. Similarly, allowing hotspots to contain up to 50% of the population was a better predictor of infection in the second year using spatial scan statistics than smaller maximum population sizes. Clusters of AMA-1 seroprevalence or parasite prevalence that are predictive of infection a year later can be identified using geospatial models. Kernel smoothing using a 1 km window and spatial scan statistics both provided accurate prediction of future infection

Breast cancer management pathways during the COVID-19 pandemic: outcomes from the UK ‘Alert Level 4’ phase of the B-MaP-C study

Abstract: Background: The B-MaP-C study aimed to determine alterations to breast cancer (BC) management during the peak transmission period of the UK COVID-19 pandemic and the potential impact of these treatment decisions. Methods: This was a national cohort study of patients with early BC undergoing multidisciplinary team (MDT)-guided treatment recommendations during the pandemic, designated ‘standard’ or ‘COVID-altered’, in the preoperative, operative and post-operative setting. Findings: Of 3776 patients (from 64 UK units) in the study, 2246 (59%) had ‘COVID-altered’ management. ‘Bridging’ endocrine therapy was used (n = 951) where theatre capacity was reduced. There was increasing access to COVID-19 low-risk theatres during the study period (59%). In line with national guidance, immediate breast reconstruction was avoided (n = 299). Where adjuvant chemotherapy was omitted (n = 81), the median benefit was only 3% (IQR 2–9%) using ‘NHS Predict’. There was the rapid adoption of new evidence-based hypofractionated radiotherapy (n = 781, from 46 units). Only 14 patients (1%) tested positive for SARS-CoV-2 during their treatment journey. Conclusions: The majority of ‘COVID-altered’ management decisions were largely in line with pre-COVID evidence-based guidelines, implying that breast cancer survival outcomes are unlikely to be negatively impacted by the pandemic. However, in this study, the potential impact of delays to BC presentation or diagnosis remains unknown

An orange will do: Suspending learner disbelief in simulations

Increasingly, educators are implementing simulation to supplement teaching. Where simulation is not already integral, difficulties have arisen with the utilization of simulation due to limited resources, training requirements, and educator uncertainty