We got word earlier this year that the American Diabetes Association was trying out a new training program dubbed a "patient simulator," where docs can practice on not-so-real people with diabetes (PWDs), trying out everything from assessing conditions to ordering lab tests and meds. And they get graded on their decision-making!
Having some actual expertise treating patients, our columnist and correspondent Wil Dubois volunteered to take a look at how realistic and useful the ADA's new simulator is.
I've got my stethoscope draped cavalierly around my neck. I don't actually need it today, but it makes me look smart. I boot up my computer and begin reviewing the case histories of the four patients in the waiting room.
Delia P. is a 65-year-old white female who "presents for follow up of poorly-controlled type 2 diabetes." Charles T. is described as a 53-year-old man who has come in for an initial visit to "establish care" after not having seen a clinician for over a year. Jorge R. is a 58-year-old obese Latino male with a 4-year history of type 2 diabetes, hypertension, and dyslipidemia. And lastly, Caroline G. is a 58-year-old African-American widow who's come in for a routine assessment of her type 2 diabetes and hypertension.
Thinking about which patient to take on first, I take a drag on my cigar and down a deep swig of Evan Williams cinnamon whiskey. Hell, why not? I'm only playing doctor today, and I'm working from home, to boot.
Don't worry, I'm not practicing medicine without a license.
I'm test-driving the new interactive patient simulator program from the American Diabetes Association and TheraSim. It's a Continuing Medical Education program for docs designed "to evaluate and reinforce best practices in the diagnosis and treatment of patients with diabetes." It's billed as the industry's first fully-interactive patient simulator.
The documentation from TheraSim says that each simulated patient is based on an actual patient case. How real will I find it? I'm told that as I diagnose and treat a patient, the system will provide me with dynamic clinical feedback — in essence, a computerized preceptor.
I decided to play the "game" straight, and make the best clinical decisions I could. But remember, I'm not a real doctor, this is waaaaaaay above my pay grade. And last week, despite having a real pilot's license, I crashed a Cessna on my son's flight simulator program while trying to land on a lake in Alaska (I don't want to talk about it). If I make a bad decision, will I "crash" my patient?
Meeting My Patient
Which patient to choose? I am tempted by the poorly controlled lady because maybe I can make simulated improvements to her simulated diabetes mess. Charles is tempting too, as he probably has some underlying issues that will need to be ferreted out. In the end, however, I choose the Latino. He's closest to the real patients I work with. I want to see if TheraSim gets him "right."
As I enter the virtual treatment room, Jorge is sitting on the exam table. I say "Hi Jorge. What brings you here to see us today?"
It's the first question on the interview list. I have to left-click to ask it.
The video screen on my computer jumps to life. "Hi Doc," says Jorge with a wave. "I'm just here for my regular checkup of my diabetes, cholesterol, and blood pressure." He has a heavy east LA accent. The treatment room is nicer than the ones we have where I work.
He's supposed to be 58 years old, but looks in his early 40's to me. He's dressed like a tradesman but is apparently an accountant. He's also listed as obese. Really? The vitals tab on my simulated medical chart shows him at 95 kilograms. Whoa! I'm no good at kilos, so I duck out of the program to Google conversion from kilos to pounds. He's 209 pounds. I don't have his height on the chart, but I'm thinking they shoulda hired a fatter actor. He's supposedly married, has one adult child, "no grandchildrens yet," and is a non-smoker. He does drink "two or three beers maybe once or twice a week." His father kicked the bucket at age 52, of a heart attack. His mom died early as well, from complications of diabetes.
He tells me, with some prompting from me, that he eats "whatever my wife makes," gets precious little exercise, and if he checks his blood sugar it doesn't seem to be included in the simulation, which strikes me as odd. Or maybe not, when you consider how rarely primary care docs look at logs.
I can only choose to ask questions on the menu. Some things that I'd probably actually ask a real patient aren't options, and I'm given the chance to ask Jorge other things I'd probably would never have thought to ask. So far it feels like I'm cheating. I've been given a script.
Exploring the Steps
The intro screen where I'm chatting with Jorge is one of seven sections. The next steps on the simulation are: history, order tests, graphs, diagnosis, orders, and results. Oh boy. I hope I don't kill my patient.
According to TheraSim, during the case simulation activities, "similar to real life, the participant can make decisions based on an unlimited number of choices."
Apparently Jorge R. has excellent simulated insurance.
Looking through the wealth of data available to me, a picture begins to emerge. It's a compelling mix of nonsense and important clues that mimic the complexity of real medicine quite well. This patient missed his last visit. His weight had been coming down, but is now rising again. I see at the last visit "we" switched his ACE-inhibitor from enalapril to losartan due to a persistent cough from the 'pril. I wonder if there's a spot I can ask about how the new med is treating him?
His BP is up a bit with the change of ACE-inhibitor. Hmmmm... I think I'll increase the dose. I click on the orders tab. A prescription pad pops up, complete with a slider to let me increase the dose. Oh how fun! I realize now I have no clue how to increase an anti-hypertensive, so I take a blind shot at the increase. I'm having flashbacks to my Alaska lake landing. While I'm in the orders section, I give him referrals to a CDE, and RD, and for exercise.
Next, I double back to labs. I'm thinking that as he missed his last visit, he might be overdue for an A1C, and sure enough he is. I order an A1C test and get instant results. Oh dear. It's 9.2%, up from 6.8 last time, according the very cool built in graph function. I get a gold star in the clinical guidance panel for catching the missing test. Well, OK, it wasn't really a gold star, it was a green check mark.
Under order tests I have the option of ordering SMBG at various times throughout the week. I click the box, and lo and behold, I get a potpourri of BG checks, running 196 to 251mg/dL, generally in the low 200s. OK, so this guy needs a basal insulin added. I go back to the prescription pad and add it on. I get another green check and Jorge doesn't cry or faint like a real patient.
So how'd I do in the end? Each decision I made was given a right or wrong rating in real time. For instance, I ordered a cardiac stress test and was told it was "unnecessary in this patient because there is no evidence that screening asymptomatic patients decreases cardiovascular events or deaths." Oops. My bad. I ordered a $4K test for no reason. But so did a third of docs who ran the simulation. When you are finished, the program compares your actions to your "peers," who are presumably real doctors for the most part, not party crashers like me.
Oddly, I "appropriately" ordered an exercise start and got a green check mark, but 0% of my peers did the same. What? I'm the only "doctor" who thinks this fat guy should get some exercise? I also got a green check mark for the insulin start, and was told it was the "best option" for the patient. But only 4% of my peers agreed. I wasn't too surprised by that; primary care docs are notoriously hesitant to start insulin, even when it's clearly needed. Hopefully, the simulators like this will begin to change those attitudes.
But no final score, damn it. The program does not give an overall assessment of how you did. Still, it was fun. Kinda like case studies on steroids.
Grading the Program
So how did the patient simulator score with me? Well, the virtual interaction with the patient seemed forced and fake to my mind --but the rich tapestry of detail, options, and decisions to be made take the patient simulator far beyond the classic case-based learning model with its moldy PowerPoints. It made me think. And I think it might make physicians think, too. Will it make docs better? It might. The combination of real-life complexity and real-time feedback feels like a winner to me.
But, damn, I sure wish I knew if my change to Jorge's blood pressure medication killed the poor guy or not. That's one thing the simulator never told me.