American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Virtual Patients are Marching toward the ACS

Courtesy of McGill University.The use of online virtual patients in our medical schools is increasing at an exponential rate. Virtual patients are proving to be effective teaching tools and are extremely popular with the students and residents.

Virtual patients provide learners with a safe environment in which to practice applying didactic material to “real” clinical situations. Cases can contain multiple challenges and can have many endings, some good and some bad, depending on the learner’s choices. They can provide feedback guiding students to standard of care choices and good outcomes. Available 24/7, students can practice until they get it right. They are self-paced and help students identify their own knowledge gaps. When virtual patient design is based on established pedagogical principles, the patients serve as very effective teaching tools. When properly positioned in the curriculum and used in a blended manner with established teaching tools and methodologies, the overall curriculum is strongly reinforced.

Further, virtual patients are acceptable surrogates for real patients when real patients with specific illnesses are not available to fulfill regulatory requirements set by accreditation bodies.

Not only can virtual patients provide a bridge between the didactic material and the real patients, they can serve as preparation for the simulation center, ensuring that students have done their homework and are well prepared before using expensive and hard to get simulation center time. Efficiencies of learning are increased while the strain on resources and cost is reduced.

On the downside, those of us who have created complete elaborated virtual patients recognize that they are labor intensive to build. They require a solid pedagogical design with a good story, lots of diagnostic and therapeutic choices based on up-to-date evidence, appropriate media, and a flow that brings the student to an ending that fulfils the objectives. A good virtual patient can take several weeks to author and once published and used by a critical mass of students, their performance and feedback will keep an author busy tweaking the case for months.

Given the amount of work required to develop and mature a good virtual patient, several ACS members have formed a group to explore the possibility of creating an ACS Virtual Patient Library. The fundamental idea is to develop a repository where virtual patients are shared by member institutes, each school contributing in a given area of expertise. Once we have been able to collect and catalogue existing cases, we can then identify curricular gaps that are common and divide up the work of creating new cases. Eventually, such a library could support a complete curriculum.

There are a number of hurdles to confront. Many authors and schools feel that there is substantial commercial value to the cases they create and are reluctant to share them. There are many applications being used to create and house the virtual patients and case content is not easily transferred from one application to another. (The MedBiquitous Group is working on standards that will make this step easier in the future, but there is considerable work to be done, particularly in terms of having authors adopt these standards.) The quality of the cases will have to be determined by standards yet to be set. Each existing virtual patient will need to be integrated at an appropriate place in the curriculum. Maintenance of the library will require funding so that a business model will need to be developed. Further, there is work to be done to have the authors of a virtual patient recognized for their work, perhaps in the way that a publication is recognized. With a concerted effort, these hurdles can be overcome.

Members of ACS-AEIs have been canvassed, and the interest reflected in the initial response suggests that the idea of a shared library is viable. Our workgroup will continue to explore the possibilities. We are setting up a space on the ACS discussion board with several threads reflecting opportunities and hurdles. Until the discussion board is ready, if you would like to join our conversation, please e-mail me at We would really like to hear from you and include your perspectives.