COLUMN. Sahlgrenska Academy has a new web application that can provide medical students with simulated patient cases on which to practice their budding skills. The program works, but it lacks content. Henrik Sjövall recounts the ups and downs of the PatSim app development process – and calls for passionate contributors to help create patient cases for the project.
One of many overlooked attractions in Gothenburg is the wharf at Gullbergsvass, which stretches all the way from the Göta Älv Bridge to the Tingstad Tunnel. A large number of boats in varying states of seaworthiness are moored there, and the further one walks from the Göta Älv Bridge, the more questionable their condition becomes. Many of these vessels will never sail again; they are lifelong renovation projects that do not seem particularly realistic.
Celemi, which had carried out many projects of this kind in the past, wanted us to add an element that would make the whole game experience a little “more fun” – perhaps a contest of some sort? The solution was to evaluate and rate the road to diagnosis, thus providing feedback about whether you asked the right questions and prescribed the right tests. They say that time is money. We set up the game in such a way that each case was assigned a “pot” of consultation time (to use to ask the right questions), and a pot of money (for the examinations and tests), and then the case manager got to decide which questions, tests and examinations were reasonable. In this way, the user could compete with himself, and could also measure his/her performance in dealing with a greater number of cases.
The user could compete with himself
The program was launched and proved very popular. Many of the participants requested a copy of the case simulation CD. Because the production was partially owned by the pharmaceutical company, it would have been inappropriate to give out copies. Still, I took note of their interest.
After a few years the pharmaceutical company shifted its focus away from the patient group, the training was discontinued, and I was allowed to take over the rights to the material. At the time, I was responsible for the internal medicine course’s “special week” in gastroenterology (the internal medicine course being a standard part of the medical education program). Thus, I had the opportunity to test out the case simulation CD on students as well – this time with supervision. This experiment went very well; the students were enthused and after each special week at least one of them would ask if he or she could get a copy of the application. If they were sufficiently assertive, I gave them the materials on a USB stick, but because the special week in gastroenterology was over, I don’t think they used it to any appreciable degree. However, the experience gave me another important perspective: Why can’t we develop something similar for the entire internal medicine course? Just imagine being able to sit at home and resolve cases in peace and quiet – that would be really cool!
I searched online, and found a wealth of similar products that were being used at other universities, including some in the United States. However, all of these examples were very complex, with video recordings, links to radiology images, clinical physiological studies, etc. I also was in contact with a group at Karolinska Hospital (Uno Fors) who were working with something similar. They warned me that the creation of complex cases was extremely resource intensive. The high level of complexity didn’t feel like it fit with our concept.
I didn’t give up. Instead, I applied for educational project grant funding to create a web application. I received SEK 500,000 and put out an offer to app designers. It turned out that in this context, a half a million Swedish kronor was “peanuts,” so we ended up with only one really interested party, a small start-up company called 23gears. They had a few preconditions, but were willing to take on the project – and so they won the contract. The owner, Steve Cook, did his best to understand what we wanted, and we held a large number of meetings on the subject. They eventually delivered a prototype that worked fairly well, and I had proud plans to launch the application. However, the app still needed to be filled with content; pretty much all it contained were some of the gastro cases from the old case simulation CD. Thus, I did two things: First, I made use of the case studies they use in the internal medicine course. Secondly, I involved a few medical students, who were given the task of adding cases in return for remuneration. It turned out that it was relatively “messy” to input cases, and the cases designed by the medical students were not quite up to scratch. I asked a few of our teachers for help, but received a relatively lukewarm response. Many teachers were critical of the arrangement (“Clinical diagnostics must be taught bedside, period!”) and I simply didn’t have time to involve myself as much as was necessary.
Then 23gears went bankrupt, and suddenly PatSim was up for sale! We had a little money left from the educational grant funds, and were able to buy the app for pennies on the dollar, thereby transferring the rights over to the university. And then we encountered yet another problem: It turned out that transferring the application onto the GU server was no walk in the park! Once we finally succeeded, we found a large number of “bugs” that made the program freeze constantly. I managed to get ahold of the programmer who wrote the code for 23gears, and he fixed the worst of the bugs – once again, for relatively little money. The application is written in a special Windows program, dot.net, which is not used very frequently, and for which it was not, therefore, so easy to find “bug fixers.”
The next event in the soap opera: A medical student, Elias Berge, comes out of the woodwork. He wants to write a project about PatSim, including an evaluation of the app. He gets tied up in the aforementioned programming problems, and spends most of his time simply making the program operational. At any rate, he manages to input more than a hundred cases into what is now (hopefully) a functional app that is also fully owned by GU. They are just sitting there now, waiting to be solved.
PatSim is waiting to be filled with content!
And that’s where we are now: PatSim is waiting to be filled with content! The cases must be quality controlled, we need more cases, and we need to test the application in a precise and thorough manner. I am currently involved in a very large number of other commitments of various kinds, and am not really equipped to be actively involved in the launch process.
Thus, the whole story culminates in the question: Is there anyone out there who might be interested in taking on this mission? The students are still enthused, it is my firm opinion that the application serves a very useful purpose (especially when it comes to the need for more practice), and the app is in tune with the current times, especially considering how constricted the healthcare system currently is.
The ship seems seaworthy – now all we need is a little wind and a good crew. Would anyone care to join us and set sail?
TEXT AND PHOTO: HENRIK SJÖVALL