St George's University of London (SGUL) has a Problem-Based Learning (PBL) curriculum for its undergraduate medicine course, using traditional paper-based patient cases. To counter the limitation that paper cases are linear and do not allow students to explore the consequences of decisions, interactive online virtual patients (VPs) were developed which allowed students to consider options as the cases unfold, and allow students to explore the consequences of their actions. A PBL module was converted to VPs, and delivered to 72 students in 10 tutorial groups, with 5 groups each week receiving VPs with options and consequences, and 5 groups receiving online VPs but without options. A comprehensive evaluation was carried out, using questionnaires, and interviews.Both tutors and students believed that the ability to explore options and consequences created a more engaging experience and encouraged students to explore their learning. They regretted the loss of paper and neither group could see any value in putting cases online without the options. SGUL is now adapting its transitional year between the early campus years and the clinical attachment years. This will include the integration of all technology-based resources with face-to-face learning and create a more adaptive, personalised, competency-based style of learning.

BackgroundThe impact of the use of video resources in primarily paper-based problem-based learning (PBL) settings has been widely explored. Although it can provide many benefits, the use of video can also hamper the critical thinking of learners in contexts where learners are developing clinical reasoning. However, the use of video has not been explored in the context of interactive virtual patients for PBL.ObjectiveA pilot study was conducted to explore how undergraduate medical students interpreted and evaluated information from video- and text-based materials presented in the context of a branched interactive online virtual patient designed for PBL. The goal was to inform the development and use of virtual patients for PBL and to inform future research in this area.MethodsAn existing virtual patient for PBL was adapted for use in video and provided as an intervention to students in the transition year of the undergraduate medicine course at St George’s, University of London. Survey instruments were used to capture student and PBL tutor experiences and perceptions of the intervention, and a formative review meeting was run with PBL tutors. Descriptive statistics were generated for the structured responses and a thematic analysis was used to identify emergent themes in the unstructured responses.ResultsAnalysis of student responses (n=119) and tutor comments (n=18) yielded 8 distinct themes relating to the perceived educational efficacy of information presented in video and text formats in a PBL context. Although some students found some characteristics of the videos beneficial, when asked to express a preference for video or text the majority of those that responded to the question (65%, 65/100) expressed a preference for text. Student responses indicated that the use of video slowed the pace of PBL and impeded students’ ability to review and critically appraise the presented information.ConclusionsOur findings suggest that text was perceived to be a better source of information than video in virtual patients for PBL. More specifically, the use of video was perceived as beneficial for providing details, visual information, and context where text was unable to do so. However, learner acceptance of text was higher in the context of PBL, particularly when targeting clinical reasoning skills. This pilot study has provided the foundation for further research into the effectiveness of different virtual patient designs for PBL.

BackgroundProblem-based learning (PBL) is well established in medical education and beyond, and continues to be developed and explored. Challenges include how to connect the somewhat abstract nature of classroom-based PBL with clinical practice and how to maintain learner engagement in the process of PBL over time.ObjectiveA study was conducted to investigate the efficacy of decision-PBL (D-PBL), a variant form of PBL that replaces linear PBL cases with virtual patients. These Web-based interactive cases provided learners with a series of patient management pathways. Learners were encouraged to consider and discuss courses of action, take their chosen management pathway, and experience the consequences of their decisions. A Web-based application was essential to allow scenarios to respond dynamically to learners’ decisions, to deliver the scenarios to multiple PBL classrooms in the same timeframe, and to record centrally the paths taken by the PBL groups.MethodsA randomized controlled trial in crossover design was run involving all learners (N=81) in the second year of the graduate entry stream for the undergraduate medicine program at St George’s University of London. Learners were randomized to study groups; half engaged in a D-PBL activity whereas the other half had a traditional linear PBL activity on the same subject material. Groups alternated D-PBL and linear PBL over the semester. The measure was mean cohort performance on specific face-to-face exam questions at the end of the semester.ResultsD-PBL groups performed better than linear PBL groups on questions related to D-PBL with the difference being statistically significant for all questions. Differences between the exam performances of the 2 groups were not statistically significant for the questions not related to D-PBL. The effect sizes for D-PBL–related questions were large and positive (>0.6) except for 1 question that showed a medium positive effect size. The effect sizes for questions not related to D-PBL were all small (≤0.3) with a mix of positive and negative values.ConclusionsThe efficacy of D-PBL was indicated by improved exam performance for learners who had D-PBL compared to those who had linear PBL. This suggests that the use of D-PBL leads to better midterm learning outcomes than linear PBL, at least for learners with prior experience with linear PBL. On the basis of tutor and student feedback, St George’s University of London and the University of Nicosia, Cyprus have replaced paper PBL cases for midstage undergraduate teaching with D-PBL virtual patients, and 6 more institutions in the ePBLnet partnership will be implementing D-PBL in Autumn 2015.

The published literature on bacterial tracheitis is limited. We report the first multi-centre study of bacterial tracheitis together with a concise review of the literature. We conducted a retrospective study of cases admitted during the period 1993-2007 to 3 tertiary paediatric centres in the United Kingdom and 1 in Australia. A total of 34 cases were identified. 31 patients (91%) required intubation. Complications included cardiorespiratory arrest in 1, ARDS in 1, hypotension in 10, toxic shock syndrome in 1 and renal failure in 1 patient(s). Staphylococcus aureus was the most commonly implicated bacterial organism, isolated from the respiratory tract in 55.8% of the cases overall. Other pathogens commonly isolated from the respiratory tract included Streptococcus pyogenes (5.9%), Streptococcus pneumoniae (11.8%) and Haemophilus influenzae (11.8%). Viral coinfection was identified in 9 (31%) of the 29 cases in whom immunofluorescence testing was performed (influenza A in 4 cases; parainfluenza 1 in 2 cases; parainfluenza 3 in 2 cases; adenovirus in 1 case). The combined experience from 4 major paediatric intensive care units suggests that bacterial tracheitis remains a rare condition with an estimated incidence of approximately 0.1/100,000 children per year. Short-term complications were common but long-term sequelae were rare. There were no fatal outcomes, which contrasts with the high historical mortality rates and likely reflects improvements in intensive care management.

-The National Health Service (NHS) is facing substantial staffing challenges arising from reduced working hours, fewer trainees and more protected training of those trainees. Although increasing consultant-delivered care helps to meet these challenges, there remains a need to remodel the workforce. One component of the solution is physician assistants (PAs), who are professionals trained in patient assessment and care, working under the supervision of trained doctors. In October 2010, three PAs began working in the paediatric intensive care unit (PICU) at St George's Hospital, Tooting, which is a large tertiary hospital. This study used surveys and semi-structured interviews to explore the process and end results of this development. Initially, there was a large discrepancy between expectations and the capabilities of the PAs. Shortly after starting, there was friction arising from PAs being untrained in PICU activities, and the facts that they would take training opportunities from other staff and that their remuneration was disproportionate to their usefulness. At five months, all those interviewed stressed the positive impact of PAs on patient care and the running of the unit. Staff had found that the PAs had integrated well and there was little evidence of earlier frictions. When surveyed at 10 months, PAs were undertaking most PICU procedures, albeit with some supervision. The study shows that PAs can be a valuable addition to the medical workforce, but that predictable problems can mar their introduction. Solutions are suggested for other units intending to follow this model.