More than 650 medical students took the first digital Objective Structured Clinical Examination (OSCE) at the beginning of the month, and the results are coming out now. This final medical test has been possible thanks to the Practicum Script Clinical Reasoning Training Simulator, which has been made available by the Practicum Foundation to five universities (Francisco de Vitoria University, European University of Madrid, CEU Cardenal Herrera of Valencia, University of Zaragoza, and the International  University of Catalonia) to relieve the impact from the current health emergency. The experience marks a milestone in Spain and opens a window of opportunity for e-medical education.

Madrid - June 23, 2020. According to Dr Eduardo Hornos, president of the Practicum Foundation and General Director of Practicum Script, "with the Covid-19, the status quo of undergraduate medical education has been questioned, perhaps for the better." The present crisis is also an opportunity to introduce educational solutions based on innovative methodologies, turning experiential learning, clinical evaluation, and communication among peers into their greatest advantages. The five universities agree that if one thing has become clear with the interruption of clinical rotations caused by the pandemic, it is that virtual clinical simulation environments help integrate knowledge and skills related to medical practice.

The design of the OSCE started at the end of February, when several OSCE Test Committees of the Spanish Conference of Medical Deans joined a series of meetings initiated by Prof Emilio Cervera, Vice Dean of Practices and Health Centers at UFV, to move the format of the competency and skills assessment test from in person to online without compromising the evaluation of the performance of the students when facing specific timed clinical situations. This resulted in a collaborative agreement with the Practicum Foundation for the application of the international clinical simulation program Practicum Script in two phases, one formative and the other one summative.

Practicum Script is a platform of cognitive acceleration that, instead of measuring learning, measures the knowledge that the student applies to solve problems related to adult patient care. The platform poses challenges that initially function as a clinical pattern recognition game for the generation of management hypotheses. During this step, an artificial intelligence system matches the hypotheses with those formulated by experts. Practicum Script then presents new data to the participants so they can decide on the impact of the new information on their hypotheses. Finally, the tool provides indicators to facilitate reflection based on the results.

The training experience, designed for the student to become  familiar with the Practicum Script methodology, was developed using a simulation of 10 real Internal Medicine  cases. During training, the students had access to a clinical debate forum mentored by professors from their respective universities. The students also had access to a digital portfolio to review their answers and had immediate feedback in the form of expert opinions and relevant scientific literature. All these benefits were available for access during the month of May. The summative test, in turn, was focused on 10 different cases selected by an interinstitutional committee and presented to the students as a 3-hour online test on June 2nd.

"The results have been very satisfactory, and the antecedent for this OSCE is the strength of Practicum Universities," mentions Prof Cervera. Practicum Universities is an initiative of the Practicum Foundation to introduce the concept of clinical uncertainty into the medical curriculum and is supported by the European Board of Medical Assessors, led by Prof Cees van der Vleuten, a recipient of the Karolinska Institutet Prize. The project has been available in more than 20 medical schools for more than 2,000 students in Europe and America, in addition to the 650 students taking the Spanish OSCE. The Imperial College London has led the preparation of the clinical cases, which have been validated by 20 experts from Harvard, Oxford, and the Charité (Berlin), among other universities. Maastricht University is in charge of the psychometry part of the project.

Learning from errors

"The beginning of clinical reasoning learning has been traditionally limited to the field of clinical practice. What we propose is to transfer to medical training the first meeting that the student has with a real patient," says Dr Hornos. He adds, "all this happens in a controlled simulation environment, so it does not involve any risk." If, in the last 30 years, medicine has embraced the widespread use of simulation to exercise psychomotor skills, cognitive training is today the greatest trump card. Practicum Script has taken up this challenge in Spain, and the coordinators of this virtual OSCE aim to see it as an alternative for the future.

In the opinion of the Prof Belén Merck, a CEU professor and coordinator of the project at the same institution, "Practicum Script has been an optimal solution to continue to train physicians and assess decision-making remotely." Along the same lines, the perception that the Unizar dean, Prof Javier Lanuza, has is that Practicum Script "is an excellent tool for the development of lasting clinical thinking skills." Prof Montserrat Virumbrales, who is the head of the Simulation Area of the International University of Catalonia, believes that "as a virtual simulator, Practicum Script combines all the potential of the reliable reproduction of clinical reality with the advantages of the digital modality, allowing students to have greater autonomy in managing their learning."

For Prof Cervera, "the presentation of the cases is attractive to the students, and the methodology is even better." Prof Cervera considers that the added value of Practicum Script lies in its impact on the student's clinical judgment. In fact, the perception of Laura González Pérez-Villacastín – from the European University of Madrid and sixth-grade delegate at the Infanta Sofía Hospital – is that Practicum Script is a platform that brings you closer to clinical practice without the pressure of treating patients in person." The student is convinced that "this has been the closest thing to continuing to rotate in the hospital." In the same way, she believes that "it has given us confidence and helped us solidify knowledge of diagnostic, treatment, and management algorithms for our future clinical practice."