Virtual Patient Cases: Improving Physical Therapy Education

Physical therapy faculty have faced unprecedented challenges in 2020. The COVID-19 pandemic, campus closures, and the move to virtual instruction have forced some creative solutions.
DxR Project Manager Jeanne Ferraro and Communications Director Beth Hart recently spoke with Dr. Karen Huhn, the guiding academic force behind VirtualPT Clinician. Dr. Huhn discussed teaching physical therapy in the new environment, and how VirtualPT Clinician can help faculty improve students develop as clinicians. Watch the video, or read the transcript below.

How do you teach Physical Therapy students online?

Q: What challenges have you faced as a result of the COVID-19 pandemic?
A: Two major factors, the first one being clinical education, getting the students out into the clinic has obviously been a challenge. And, academically, for didactic portions of the program, the big challenges have been around lab experiences, teaching the manual skills, the physical skills, how do we do that when they are not in lab with us. Many of our programs are very heavily lab-based for instruction, and since we can’t do those, that has been the other big challenge, how to figure out how to deliver and assess the students on those skills when we can’t be in the Lab with them.

Q: How do you think you as faculty members have adapted to these challenges?

A: Slowly. [Laughs.] I think we are getting better. I think we are much better prepared for in the Fall than we were to do it overnight, in the Spring. We have learned a lot about technology and how we can use technology to have the students videoing themselves doing, practicing skills, and us being able to watch the video and be able to assess and provide feedback. So, faculty recording videos of them performing the activity, sending that to students, having students practice it, send their videos of them practicing, and then letting the students decide which is their final submission for them performing a skill and being able to give them feedback on that. I don’t think we can do it for all the things we have to teach, but I think that that’s how we have adapted, mostly. Using simulations for some things, especially around acute care, but that’s been challenging too, because we kind of need them on campus for that. So that I think, has been our biggest challenge: our lab skills and finding ways to do those distance-wise, primarily using video.

How can virtual patient cases help PT faculty teach online?

Q: How do you think resources like VirtualPT Clinician have played into how you have been able to adapt?

A: I think it’s fabulous because it is a great way, during a pandemic or not, to expose students to a wide variety of patient cases and have them think through the cases. Our being able to see, sort of visualize the student’s thought processes because of the way the program tracks what the students do in the program. And students being able to do that no matter where they are, as long as they have internet access. They could do it anywhere and any time. So it is easy to work around when we are doing synchronous lectures online, students can be doing these cases at any time, and then we can see what they did and still give them feedback, again, on our own time, whenever we get to it.
So there is a lot of flexibility in using it. But, I think, it’s obviously best at the Clinical Reasoning process but it is also very good for exposing students to a wide variety of patient cases, types and kinds of patient cases.

Q: …and a consistent experience across the class…

A: Right, I can expose all my students to the same case and know they have all experienced that same diagnosis, that same patient in traction, the same cultural aspects of the case, quite easily.

How is physical therapy education changing?

Q: As you are facing going forward into the Fall, in an unknown circumstance, I guess, and the going forward into who knows… do you see some of the lessons or some of the applications that you as faculty members have made applying going forward and being used more readily?

A: Yes, I think so..I think you are going to see some permanent changes to PT education as we get more creative and realize what is ‘absolutely needs to know’ and ‘what’s nice to know.’ I think a lot of the tools we developed during this time will continue and will change the way we educate PTs (Physical Therapists) in the future. But we’re not going to give up our hands-on completely.

How do virtual patient cases improve physical therapy education?

Q: When you helped develop VirtualPT Clinician, you were obviously responding to something you saw as a need in the education process. What did you see as the need and how does this program meet that need?

A: So, what I saw as the need was the ability to expose students to a lot more patient cases than we had been able to do. PT is a little different: when we send them into the clinic, it is not PT faculty out there with them. They are with clinicians, so carrying what we are teaching them into the clinic is not as easy as it is in nursing, where the faculty go with them, or pharmacy, where they go with them.
So being able to expose student so a whole bunch of, a lot of cases to build illness scripts, to start chunking their thinking together, take all that basic science knowledge and give it a clinical context. We didn’t have a way to do that. We were doing that with paper cases, and the big limit with paper cases, is that you were giving the student information, they didn’t have to decide what information was needed, what questions they had to ask, what tests and measures did they have to do. You had no choice but to give them the information. So the virtual patient cases allow you to expose student to a lot of cases and give them very minimal information. That is very similar to what they are going to get in the clinic. The patient comes in and says, ‘My shoulder hurts!” And that’s all they volunteer, and that’s same way in the virtual cases. The students have to be able to decide what information they need to know and how do they go about getting it.

How do faculty benefit from using virtual patient cases?

Q: And the, you as a faculty member, what do you see as the payoff?

A: The payoff for me is that…we really have no way to assess clinical reasoning. We really don’t even have a way to understand how well a student is reasoning through a case other than by talking to them, and most of our class sizes are too big to allow us to do that.
The Virtual Patient (VirtualPT Clinician) program allows me to do that, because the student is working individually, I get feedback on their reasoning process, I can see what they did, I can see where they missed things, where they are really good at other things.
And then, I can give them individualized feedback on that, and hopefully, the next case they do, they correct whatever issue they saw in the first one. And I can help them move their clinical reasoning along, and improve it. I had no way to do that before, because, you know, you’re usually doing case in a group, and as always when you’re working, the stronger students are speaking out, the quieter students are not. This (VirtualPT Clinician) does not allow a student to not reason through a case individually, so I love being able to give individualized feedback. I think that’s super important for clinical reasoning.

How to make the most of virtual patient cases: The Debriefing

Q: And the role of debriefing in this whole process. Tell me about the you approach that and the importance of that.

A: I love the debriefing. The debriefing is after the students do a case. And I look at how the students did, and I look for trends, you know, either the majority of the class did do this or didn’t do this, and then I go back to them and I ask them about that. “I noticed that half of you didn’t put Pain on your problem list. DO you think pain is a problem for this patient?” and of course, they are all saying, “Yes.”
“OK, why did you not consider that was something you needed to put on your problem list to intervene on?”
And then we have a discussion about why, and some of the answers are great. “Well, I assumed that once I improved their strength their pain would go away.” That’s legit.

So it turns into a really nice conversation about how they arrived at whatever they arrived at. Then we can have a discussion about that. So it is very much a discussion, it is very much back-and-forth, it is very low stakes, it’s not, I don’t find the students get defensive about their answers or their justifications, as long as I ask in a very inquisitive way. I kind of ask, ‘What the heck were you thinking?’ in a nice way.
The debriefing is really fun because I find sometimes is what I expected them to do they didn’t do, but they have a good rationale for why they didn’t do it, which is acceptable and very true to clinical practice.

Q: Our founder always said, “Get inside the student’s head.”

A: Absolutely, that’s the best part of this program. That’s what it lets you do. I can see what they were thinking, and if I can’t tell what they were thinking, I can see enough to go back and ask them, ‘What were you thinking at this point? You got this piece of information, you didn’t do anything with it. Tell me why didn’t you. Why didn’t you think that was important?’ So it’s also a great way to get the students to talk about their own thought process.

Q: And if there’s an error, you can correct it before it shows up in clinic.

A: Absolutely.

How to save time and provide valuable feedback to students

Q: I know that you and your colleagues face a lot of pressures with time. How do you maximize the learning outcomes form these kinds of experiences that you assign to your students?

A: Obviously, I am very comfortable with the program, but I find when I first started to use the program.
The program has a nice option to do individualized feedback or group feedback, and you can look at the class trends as a whole, and that’s a great way to start. It is not time consuming, you can look at those in a few minutes. You can look for big issues that the class either got or didn’t get and just debrief on those things, and you are still going to make a nice improvement. Either they misunderstood a concept you thought you taught very well, or you realize you didn’t make this really clear to them. You don’t know why they didn’t do it and now you can go back and ask them.
So it is really nice to do a debrief with the class and see what the class trends were. We find this very commonly: There is a patient case that is two days post total hip replacement, and the students all prescribe a walker for the patient. None of them assess upper extremity strength. So none of them ever determine, “Does she have the strength and the hand strength to use a walker?” And as soon as I say something to them like, ‘How do you know she has the strength to use that walker you just prescribed?” And they are like, ‘Oh, we should have checked upper extremity strength!’
Those are common things that are really easy to see and make those connections for the students when they miss things like that. That’s a simple correction to make. Then they never miss it again.

Q: I would think they would remember that. I think the whole concept of learning through a story, people remember stories….

A: Exactly. In the same case, you know, she had the hip replacement because of arthritis, she also had arthritis in the other knee and they also don’t think of that. They get so focused on the hip, they forget she has arthritis in the other joints. And I can talk them through that.
“Where is she putting all that weight, now that she’s had that right hip replaced?”
They are like, “On the left leg.”
And I am like, “And how’s that left knee?” And they are like, “Oh, yeah! She’s got arthritis there!”
Those are the kinds of connections that are so easy to make in program like this.

Q: Teachable moments.

A: Yes, absolutely! They are huge, huge with this program!

Getting started with virtual patient cases

Q: So, if you were talking with a faculty member who wanted to start learning about VirtualPT Clinician, how would to sum up what the program is and does? Then I am going to ask you about you as a ‘power user.’

A: If a new faculty member was using it, I would encourage them to pick some of the cases that are already written. There are 20-30 cases that are already written. To take one of those, and we have cases that are written for first-year students, with low expectations of what they will able to do. I would start there. The criteria are already set up, but if you want to change a few of them because you haven’t taught something yet, you could easily change that. And I would start there. And I would start with giving them a single case, and doing a class debriefing, just looking at class feedback and doing a debrief based on that.
Once you did that once or twice, then I think you would want to know more, and you would start looking at the individual. Or you will see that there’s consistently one individual in the group who doesn’t do what they rest of the class did, and you might want to give feedback to those few students who you can see were really not around the class averages.
That’s how I would start using it. And I would start using it very early in the curriculum. We use it in the first class they take in the curriculum to get them thinking like a PT early. So for a new faculty member, I would use the cases we already have, and do class debriefs before you get into the individualized feedback.

Expert Tip #1: Save time and provide great feedback using Statistics feature

Q: And then you as a power user of VirtualPT (Clinician). It was your brainchild and because you have been using it for so consistently, you may have some pro-tips for other users. What one of your best pro-tips?

A: I will still go to those class statistics, and when I see a criteria item that I wanted them to do and they didn’t do it, I can click on that and it will tell me which students didn’t do it. And I will look consistently to see which students aren’t doing the things that I want, and then I will give them individualized feedback.
I like to give individualized feedback to everybody, but when I first start a class doing the cases, I do the group feedback, and then I move into the individualized. And I have learned what the program grades for me and where I really need to focus, which is usually on the goals, because the program doesn’t grade the goals.
And I have gotten very good at, when I write the criteria, what I want them to put on their problem list of using synonyms. So I know how students tend to misspell ‘tendonitis,’ so I will put that in the Synonyms list. So I have gotten very good for both the Problem and the Hypothesis list of putting the words that they students commonly use, so the computer is more effective at self-grading. Then I can very quickly go through those categories, and I can very quickly look at what History or Exam items the students didn’t do.
By doing those things, I can now grade an individual record in, you know, under five minutes. So for a class of 40, in hour, I can go through all of them.

Q: A lot faster than a paper case.

A: Yes, and that’s with so much more information. And the software allows me, especially when I look at their Goals that they wrote for the patient, to give them individualized feedback on their goal writing, which is something I think a lot of PT students struggle with. and I can very quickly give them feedback on that. So even with doing that, I can still do [grade] 45 of our students in an hour.

Get inside PT students’ heads

Q: When you are telling other faculty members about this program, what do you tell them, how do you sum it up in a quick summary?

A: You get in the student’s head. You get to see what’s in a student’s head. You get to visualize their clinical reasoning process. And that’s usually enough because faculty know we have no way to do that. There isn’t another good way to do that. To me, that’s the key…that, and the individualized work, you know, making the students do their own case. Then I usually tell how how unrealistic it is to give them a paper case where we are feeding them information, because that’s not how it is in the clinic.

Q: And this is one of the very few programs designed specifically for PT education.

A: It’s the only one I know of. [Laughs] I have seen some other patient simulations, but they are basically just taking a case and ‘acting it out.’ It still doesn’t have the power of letting you see the reasoning process that VirtualPT [Clinician] has.

Improving Clinical Reasoning

Q: As you see the evolution of PT Education, and this program, how would you see this advancing PT education?

A: I think mostly in the area of clinical reasoning, which is one of the big areas that we all struggle with. We know that a new clinician is still not good at clinical reasoning, there’s still a good 5 or 10 years of clinical practice that needs to happen for them to get good at clinical reasoning. I think this program allows them to shorten that gap, and I think they can be better at clinical reasoning once they enter the clinic, and I think it makes the process more explicit for the students, so they understand the process better.
How I’m going to talk to my faculty about it when they come back on Monday is that it is a great way to expose the students to more cases and to use the video components, use the heart rate, the ECG, EMG..all the things, all the media we can put into the virtual cases to make the cases more realistic. I think they could be used for skills checks and for OSCEs (Objective Structured Clinical Exams) and things like that.
So I’m going be pushing my faculty to do a lot more of the cases since we aren’t going to have the students in front of us as much. I can’t grill them, I can’t ask them, Why? Tell my why. Tell me why. This program allows me to do that when they are not in front of me.

I’m actually kind of excited, I am hoping more faculty will spent time getting to know this program. I think it will really help as we do more distance education. I am hoping more faculty will realize the power of it.

Dr. Karen Huhn, PT PhD, is Professor and Chair School of Physical Therapy at Husson University in Bangor, Maine. She helped develop the template for DxR Development Group’s VirtualPT Clinician software. DxR Development Group and Karen Huhn have a business relationship. Dr. Huhn could receive a nominal royalty from sale of individual VirtualPT patient cases.