Sorting Out the Virtual Patient: How to Exploit Artificial Intelligence, Game Technology and Sound Educational Practices to Create Engaging Role-Playing Simulations

Sorting Out the Virtual Patient: How to Exploit Artificial Intelligence, Game Technology and Sound Educational Practices to Create Engaging Role-Playing Simulations

Thomas B. Talbot, Kenji Sagae, Bruce John, Albert A. Rizzo
DOI: 10.4018/jgcms.2012070101
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Since Dr. Howard Barrows (1964) introduced the human standardized patient in 1963, there have been attempts to game a computer-based simulacrum of a patient encounter; the first being a heart attack simulation using the online PLATO system (Bitzer, 1966). With the now ubiquitous use of computers in medicine, interest and effort have expended in the area of Virtual Patients (VPs). One problem in trying to understand VPs is that there are several quite distinct educational approaches that are all called a ‘virtual patient.’ This article is not a general review of virtual patients as current reviews of excellent quality exist (Poulton & Balasubramaniam, 2011; Cook & Triola, 2009). Also, research that demonstrates the efficacy of virtual patients is ample (Triola, et al., 2006). This article assesses the different kinds of things the authors call “virtual patients”, which are often mutually exclusive approaches, then analyzes their interaction structure or ‘game-play’, and considers the best use scenarios for that design strategy. This article also explores dialogue-based conversational agents as virtual patients and the technology approaches to creating them. Finally, the authors offer a theoretical approach that synthesizes several educational approaches over the course of a medical encounter and recommend the optimal technology for the type of encounter desired.
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A Whirlwind Tour Of Virtual Patients

As previously stated, many different entities with unique approaches and attributes are all often called virtual patients. Such approaches include case presentations, interactive patient scenarios, virtual patient games, human standardized patients, high fidelity software simulations, high fidelity manikins and virtual human conversational agents. Salient features of these virtual patient approaches are summarized in Table 1.

Table 1.
A comparison of different methods for simulating a patient encounter. All of these techniques have been called “virtual patients” though the term is most commonly associated with interactive patient scenarios. Estimations in this table are author opinions based upon experience developing simulated medical encounters.
Case PresentationsInteractive Patient ScenariosVirtual Patient GameHigh Fidelity Software SimulationsHuman Standardized PatientsHigh Fidelity ManikinsVirtual Standardized Patient
Common NamesOnline Virtual PatientVirtual Patient,
Multimedia Sim,
Branching Scenario
VR Simulation,
Virtual Patient Avatar
Medical Simulation,
VR Surgical Simulator
Standardized Patient,
Patient Actor
Manikin, Task TrainerVirtual Human, Conversational Agent
Teaching ApplicationsBasic Knowledge,
Clinical Reasoning
Clinical ReasoningProcedures
High-risk scenarios
Team Training
Complex Procedures
High-risk scenarios
Patient History
Physical Exam
Patient Counseling
Team Training
Patient History
Patient Counseling
Learner Skills EvaluatedKnowledge,
Pattern Recognition
Clinical ReasoningClinical Reasoning,
Procedural Reasoning
Physical Diagnosis
Procedural Skills,
Critical Interventions
Interview Skills,
Physical Diagnosis
Clinical Protocols,
Physical Diagnosis
Team Performance,
Interview Skills
InteractivityVery LowLow-ModerateModerate-HighHighVery HighModerateVery High
Consistency of Experience & EvaluationHighHighModerateHighVery LowLow-ModerateHigh
Flexibility to Recover
from Learner Errors
Suitable for Game-based approach?NoneModerateHighModerateNoneLowHigh
Authoring ChallengeLowModerateHighVery HighLowModerateHigh
Core TechnologyText,
Physiology Engine,
Virtual Reality Tissue,
NoneVariesDialogue AI,
Natural Language
Enabling TechnologyHTML,
Authoring Tools
Actionscript, etc., Authoring Tool
Game EngineGame Engine,
Anatomy Database,
Haptic Controllers
Written Script,
Video Recorder,
Human Monitor
Sensors & Actuators,
Wireless Data
3D Game Engine,
Speech Synthesis,
Non-Verbal Behavior,
Speech Recognition

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