June 21 2018

A few years ago, the directors of the basic medicine clerkship at the Johns Hopkins University School of Medicine were concerned that in the current era of high-value care, third-year medical students were not necessarily learning how to order medical tests appropriately. So clerkship leaders Amit Pahwa and Danelle Cayea banded together to create an online case-based module called the Hopkins Virtual Patient.

Through the program, says Cayea, director of the medicine core clerkship program and associate vice chair for education for the Department of Medicine, students evaluate three hypothetical patients: one with acute kidney injury, one with an exacerbation of chronic obstructive pulmonary disease and one who developed a blood clot in her leg following surgery.

After reviewing information about each case, students select the tests they feel are appropriate to order from a drop-down menu. The menu also lists the Medicare allowable fee or average wholesale price, to provide experience with Maryland’s Global Budget Revenue and its capitated payment system that reimburses a fixed fee per patient. Upon completion of the module, which takes about one to two hours, students receive a score based on the appropriateness of the tests they chose and the money they spent. The work was funded with a $50,000 Berkheimer Faculty Education Scholar Grant from Johns Hopkins’ Institute for Excellence in Education.

One reason they developed the course, says Pahwa, associate director of the core clerkship in pediatrics and director of the advanced clerkship in internal medicine at The Johns Hopkins Hospital, is that much of patient care learning lies in apprenticeship, where students observe how their supervising physicians manage patients. But everyone has his or her own approach, and some of those approaches may include practices that are not evidence-based, says Pahwa.

In addition, students spend their clerkship on a large inpatient team. While that’s great for patient care, it’s tough for educators to determine which parts of a care plan were suggested by students, making it difficult to assess how well students are learning value-based care.

As Pahwa and Cayea brainstormed how to teach these concepts, Pahwa’s wife—a pediatrician and “superuser” of the Epic electronic medical record system—had an inspired idea: Why not establish a virtual learning playground where students could practice ordering tests without affecting the hospitals’ bottom line?

The scores received on the module don’t impact students’ grades, but do train them in appropriate test ordering patterns for the three conditions presented in the modules, says Pahwa. Overall, he notes, the better students perform on the modules, the better they tend to do in the clerkship itself: “What that indicates is that these modules help tell students how well they’re doing in seeing patients, talking to them and eliciting information to order tests appropriately.”

The modules may be adopted by MedU (soon to become Aquifer), a national provider of web-based medical education materials.