Virtual Humans Versus Standardized Patients: Which Lead Residents to More Correct Diagnoses?

Medical educators often use standardized patient (SP) encounters to train and assess a novice’s ability to gather history, to perform physical examinations, and to synthesize data to form diagnoses. These types of encounters have even been incorporated into various high-stakes exams, such as the Medical Council of Canada’s Qualifying Examination Part II (since 1996), the Educational Commission for Foreign Medical Graduates’ Clinical Skills Assessment (from 1998 to 2004), and the United States Medical Licensing Exam Step 2 Clinical Skills Assessment (since 2004).1–3 Yet, we believe possible limitations exist with this method of training and assessment. While deficiencies in performance may be due to inexperience and lack of skill or knowledge on the part of the examinee, they may also be due to flaws inherent in human SPs. Various studies examining the use of SPs in trainee assessments have found predominantly promising results, suggesting that performance during clinical skills assessments with SPs during high-stakes exams not only has high validity, but also predicts performance on similar high-stakes exams. Further, these studies demonstrate that SP ethnicity, nationality, gender, and primary language have at most only a minor influence on the student’s performance.4–14 However, we found no study that has reported what influence abnormal physical findings have on the decision-making abilities of examinees during clinical skills assessments. SPs may not deliver a consistent history, especially over multiple repetitions, and they frequently cannot exhibit abnormal physical findings. They are typically healthy, ambulatory adults who have essentially no consistent physical findings, even though they are tasked with presenting many common diseases that are associated with significant abnormal physical findings. While real patients who are able to present actual disease states can and should participate in medical training, their inconsistent availability limits the uniform educational experiences of students. Some investigators have addressed these limitations with “augmented” SP encounters. Sun and colleagues used modified stethoscopes that could play abnormal auscultatory findings during physical exams of SPs.15 Sun further augmented SP encounters with virtual pathology echocardiograms that utilized tracking technology to display an abnormal exam when the echo probe was in an appropriate anatomic location over a patient’s thorax.16 While promising, these techniques can neither discern nor display disease conditions that affect the physical appearance of the patient. The Virtual Experiences Research Group (VERG; Gainesville, Florida) is exploring human-to-virtual human interactions with unique applications of virtual reality. VERG developed a highly immersive virtual human (VH) for this purpose. The VH enables the presentation of a consistent history and abnormal physical findings for multiple learners. Some medical educators have already used the VH to assess medical students and teach them communication skills.17 Moreover, VERG merged the VH with a mannequin to create a mixed reality simulation for breast exams.18 While the SP supply is limited, the VH offers the exciting possibility of creating an almost limitless repository of diverse and challenging virtual clinical scenarios that are difficult to consistently duplicate with authentic SPs. The purpose of this study was to determine if junior anesthesiology residents would more frequently suspect obstructive sleep apnea (OSA) during a preoperative exam of a VH as compared to an SP.