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MEDSCAPE EDUCATION: The Human Story in Virtual Patient Simulation


Stories are shared experiences, where meaning-centered approaches and coping strategies ascribe cultural meaning
to events and emotions; a way to merge the individual and the collective experience into the same therapeutic process.[Steffen 1997] It may be that humans—who first had to rely on memory to learn anything—are hard-wired to accept information predominantly through storytelling, “triggering an ancient muscle memory of imagination.”[Duncan 2014]
How ancient? At least 73,000 years ago, cave dwellers used ocher and rock to etch the same symbols repeatedly and globally, but their meaning is lost to us.[Gabbatiss 2018] Fast forward 38,000 years, and a cave painting of a small, curly-tailed creature, a female babirusa, became “our closest link yet to the moment when the human mind, with its unique capacity for imagination and symbolism, switched on.”[Marchant 2016] Those painted stories gave form to human imagination—a vital component of progress. [Reese 2018] In fact, many historians and psychologists believe
storytelling is one of the elements that defines mankind and bring us together as a species.[ 2019]

Storytelling is like a flight simulator for life, but for it to be effective it needs to be believable … and carry emotional weight.


Without a story, it’s almost impossible to spark imagination. Stories train our brains to envision solutions to problems, and whole civilizations were founded on that ability. Stories stick with us because they tap into the core of what makes us human.[Reid 2018] Studies on how narratives affect the mind have shown repeatedly how strongly stories influence our attitudes, values, and even actions. Indeed, one study showed a movie about a terminally ill child to participants who were then given the opportunity to donate to a related charity—nearly all of them did so.[Zak 2013; Zak 2015] According to Distinguished Fellow and professor, Jonathan Gotschall (Washington & Jefferson College), fiction may even be more effective in shaping our beliefs than a story that relies on reason and evidence.[Gotshall 2012] So, when we’re engrossed in a movie or a book, we’re taking an emotional journey made compelling by a storyline that engages, teaches and potentially motivates us to act.[Walker 2019] “Your brain ‘on story’ is different than your brain when it is receiving any other form of information, including straight facts and data,” says Northwestern University Professor Emerita, Michele Weldon.[Weldon 2017] Simply put, a story clears a path forward to learning.

Tell me, I forget. Show me, I remember. Involve me, I understand.
– XUN KUANG (312-230 BC)


According to the late, esteemed psychologist Jerome Bruner, there are 2 modes of thought: first, paradigmatic or scientific, defined by logic, observations, and experience to categorize, conceptualize, organize, and test for verifiability, establishing “what is” or the reality of a thing. The second mode is narrative, which explains the world through stories, the search for meaning, and the individual and collective human experience over time. “A paradigmatic explanation proves; a narrative explanation illustrates.”[Gooblar 2015; Bruner 1986] These modes are complementary and work well in tandem.
The deceased, famed educator Edgar Dale defined subsections of these modes, and correlated each to how much we retain and for how long, characterizing them as either passive or active learning. (See Figure 1) Much of what we learn and how much we remember, then, is determined by how we receive and interact with the information being presented to us.


Professor Weldon is emphatic: “There are proven intersections between neuroscience, biology, and story that we cannot ignore. The threads of stories that we read, hear, watch, and click on affect us intrinsically.”[Weldon 2017] Functional magnetic resonance imaging (MRI) has advanced neurobiological research by showing heightened connectivity in the left temporal cortex, not just while, or just after, reading such stories, but for several days; almost an ingrained memory.[Clark 2013; Weldon 2017] But it’s more visceral than just the brain: when people were given stories to read that were based on empathy and emotion, blood samples taken before and after they read the stories found greater levels of cortisol and oxytocin in the latter. Oxytocin, sometimes called the human bonding or empathy chemical, also controls some human behaviors and social interaction.[Weldon 2017; Hormone Health Network 2018] At a fundamental level, a well-designed narrative makes us care—and who are likely to hear more oxytocin producing stories than healthcare providers?

By three methods we may learnwisdom: First, by reflection, which is noblest; second, by imitation, which is easiest; and third, by experience, which is the bitterest. CONFUCIUS (551-479 BC)


The immediate benefit of simulation learning in healthcare is that it turns a normally patient-centered encounter into an exclusively learner-focused experience where complex clinical skills can be acquired without actually treating a living being.[McDougall 2015] Learning in healthcare is often tied to an apprenticeship of sorts and based on a curriculum that, hopefully, provides enough of the same situations to ensure learners become skilled in resolving them. That’s a hit-or-miss way to learn and is potentially unfavorable to both learners and patients. Simulations, in turn, provide situated learning[Lave 1991], and “a process whereby trainees gain orientation to a professional culture by participating in activities of the practice through a limited, mentored apprenticeship, gradually assuming responsibility over time." [McCoy 2016]

Critical thinking and hands-on skills, at-will repetition, diagnostic and treatment strategies, procedures, effective communication, and decision making all can be woven into a simulation, scheduled for convenience, and repeated as often as needed. Ultimately, “simulations offer opportunities to review concepts, retry, and finally attain a better score”[McCoy 2016]. Learners who choose incorrectly or make mistakes are inspired to seek more information. Seeing the risk-free consequences of their mistakes lets learners gain significant insights and stimulates the need to “get it right.” All of this, in turn, gives the greatest freedom of all to physicians: The freedom to act and learn without endangering patients.

Simulation also provides a customized learning experience, accommodating beginners and experts by giving them time to absorb situations and master tasks—even rare ones—before they’re needed. Moreover, it allows for review, feedback, and evaluation when they will do the most good—immediately—as opposed to trying to fit them around the real-time pace of healthcare events. Controlled simulations, which are “fast becoming a vital source of experiential learning in medical education,” according to Western Illinois Professor Michael Curtis, can incorporate all of those elements, further strengthening their purpose and use.[Curtis 2012]

There is strong evidence that virtual simulations result in positive learning experiences and are proven to stimulate engagement, as well as support deliberate practice in clinical reasoning.[McCoy 2016] A 2009 review of the literature identified 8 studies, all resulting in significantly increased learning. When compared to other instructional formats, the authors identified another 4 studies with favorable results.[Cook 2009; McCoy 2016]


Simulation in healthcare isn’t new. Thousands of years ago, intricate models were employed in the teaching of anatomy, physiology, and surgery. In the 18th century, simulators that leaked ‘amniotic fluid’ and ‘blood’ helped healthcare professionals learn to recognize and manage complications of childbirth.[Owen 2012]

In the late 1950s, cardiopulmonary resuscitation mannequins simulated a more realistic narrative. The 60s ushered in vastly more expensive computer-controlled patient simulators that could only train those onsite, and only one at a time.[Barnes 2010] But, 20 years later, the narrative of car crash-test dummies Larry and Vince brought about wholesale change without a physical presence. As recently as 1985, only 21% of Americans buckled up, but the revolutionary ad campaign showing what happens to people in a car crash without seatbelts led to their use more than tripling by 1999.[Taylor 2017]


If the benefits of educational technologies in medical education were obvious, so was the clear next step: marrying the power of narrative with experiential learning, or virtual patient simulation (VPS), to elevate education interventions from the realm of memorization to that of deep-rooted understanding [Pedagogy in Action 2019].
If a strong narrative with emotional freight makes us think and remember, it automatically adds a consequential factor to instructional design. With VPS, it enjoys a symbiotic relationship: While narrative design is the story of the VPS—the what and the how—the VPS is its heartbeat.

VPS in medical education takes its cues from serious games and the best practices of simulation design, becoming an vital part of the planning process,—along with the concepts and events designers want learners to experience in the patient’s world. To achieve the desired results, a VPS needs to be goal-oriented, rule-based, case-based, and engage learners in active decision making. (Figure 2) It also needs to provide a system of rewards for achievement as well as robust informative and summative feedback for actions that do not align with the goals of the intervention.[Warters 2019; McCoy 2016] This is as true of a video game with an involving story as it is of a VPS.

Medscape examined the activity data from its own free, online, VPS platform, MedSims—which has educated over 800,000 learners in the past 4 years alone—and found strong and consistent benefits to its inclusion as a learning modality, presenting 61 scientific posters on related outcomes since 2014, including 17 in 2019 alone. Furthermore, a systematic review of the effectiveness of VPS in health professions education looked at data from 25 trials comparing VPS with traditional education [N=927]. The pooled analysis showed similar results for knowledge but favored VPS for competencies including clinical reasoning, procedural skills, and a mix of procedural and team skills. [Konowicz 2019]

Likewise, studies have shown multiple benefits from VPS replacing traditional clinical hours among nursing students—particularly in clinical competency, critical thinking, content knowledge, and self-confidence.[Jimenez 2017]
In short, a well-designed VPS with a powerful narrative is a structured scenario to teach and develop competencies that can be applied to real-world practice. VPS provides both story-supported learning that encourages engagement in complex analysis and opportunities to increase skills and capabilities, as well as allows for decision making within an ever-evolving clinical scenario.[Warters 2019]  


Designing a VPS is a holistic effort and the sphere of components, below, represents how each factor interacts with and relies on the others for its structural integrity.

We start with the core of what will make the simulation a success—the learning goals. The next layer is what we want learners to experience, along with the behaviors and rules surrounding that experience. The population we want to reach comes after that. Finally, everything is wrapped in the narrative skin, which tells the story of the simulation and sets the education up for success. [Warters 2019]

For more information, contact your Medscape Account Team or contact us through our PM HUB

You can also download this White Paper here.


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23rd June 2022