Transcript Can virtual patients detect cognitive error?

SimuCase For Teaching And Testing
Clinical Reasoning: A Pilot Study
Timothy Willett
Simon Abrahamson
Angele Landriault
Pierre Cardinal
Patti O’Brien
Brad Genereaux
SimuCase
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Media-rich virtual patient
Facilitated small group sessions
Completely non-leading
Can treat before investigating/diagnosing
Complement to high-fidelity simulation
Hypothesis
Virtual patients can be constructed and delivered in
ways that will elicit the clinical reasoning of students
and allow for cognitive errors, thereby permitting
feedback on reasoning strategies and metacognition.
Participants who have invested in a diagnosis of septic
shock will commit a fixation error, failing to recognize
concomitant anaphylaxis.
Methods: Target population
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National ACES 2008
Residents about to start critical care fellowships
6 groups, 5-10 per group, 1 hour
Received a 1-hour sepsis lecture in the AM
Methods: The SimuCase – Phase 1
• Initial presentation: 72-year-old man presents to ER
with altered LOC, agitation and confusion x1 day
• PMHx: smoker, HTN, DM-II
• Behind the scenes
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Septic shock
Must be sedated to be examined
O2 sats fall until intubated
BP falls until IV fluids and vasopressors
IV antibiotics needed
Patient will stabilize
Methods: The SimuCase – Phase 2
• Trigger video: Ventilator high pressure alarm
• Behind the scenes
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Anaphylactic reaction to antibiotics
Auscultation: wheezes
Derm: Blanching urticaria on upper legs
BP and O2 begin falling again
Epinephrine needed
Methods: Setup
Trigge
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Until sedated, intubated, stabilized, abx given video
A
Phase 1
B
C
E
F
Phase 2
Summary of group A
Phase 2
Phase 2
Phase 1
D
20 min
Summary of group C
Phase 2
Phase 2
Phase 1
Summary of group D
Phase 2
Results: Phase 1
• Groups A, C, E
• Resuscitation:
 All sedated then eventually intubated
 Gave 3.0 / 5.5 / 3.0 L
 All used phenylephrine and norepinephrine
• Sepsis:
 2/3 drew blood cultures
 2 gave pip-tazo, 1 gave meropenem
 Abx at 17 / 35 / 22 minutes
Results: Phase 2
• Groups A, C, E: None dx anaphylaxis
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All examined chest, gave salbutamol & IV hydrocortisone
2 voiced consideration of additional dx
Gave 3.5 / 1.0 / 4.0 L additional
2 added vasopressin, 1 added dopamine
• Groups B, D, F: 2 dx anaphylaxis
 Both vocalized “something else going on” (12 / 5 min)
 Made dx at 16 / 19 min – immediately gave epinephrine
 All gave fluids, vasoactive drugs, hydrocortisone
Conclusions
• Modest: Not generalizable
• SimuCases can be designed to trap participants in
cognitive errors
• Appears participants are vulnerable to fixation errors
even in virtual simulations
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