Interactive Medical Cases Introduced on New England Journal of Medicine Website

The New England Journal of Medicine, which offers a variety of medically related cases online, including original research articles as well as review articles, is used by doctors to stay up to date in medical advances, recently added a new item to its online content: an interactive medical case.

The interactive medical case is touted by periodical as presenting "an evolving patient history and a series of questions and exercises designed to test your diagnostic and therapeutic skills." In fact such interactive cases may represent the future of medical education in the United States, as well as in many different countries around the world.

Traditionally, medical education, as well as continuing medical education for already established doctors, consists of reading detailed information about a variety of diseases. Original articles in the New England Journal of Medicine also importantly describe future medical therapies in development and how they may figure into practice. Doctors who have been practicing for years, even decades, are able to easily integrate new research articles into their practice.

However, for doctors in training just out of medical school, a large amount of the learning curve is spent learning how to diagnose and treat patients, part of critical clinical problem solving skills. Because such a learning process is often hit and misses, with young doctors learning more from their mistakes than from their successes, medical educators have for years been pondering developing online interactive cases. This is because interactive computer simulated patient encounters offer the opportunity for student doctors to make decisions, before they will impact real patients.

The New England Journal of Medicine appears to have taken the next step in this process by offering, for a limited time, pilot interactive cases on its website.

In the opening comments a woman, in brief, presents to a doctor's office with five hours of bleeding from her gums after a dental procedure. This bleeding persisted despite pressure being applied, and she had a similar episode 6 months ago.

Normally, when a patient presents with uncontrolled bleeding, such as after a dental procedure, it alerts the doctor to a problem with the mechanism of blood clotting, with could signify a defect with how a person's platelets function or with coagulation factors, both of which are important to clot blood and stop bleeding when it occurs.

After I click the "Continue" button, the next page of information contains information about the patient's medical history. Surprisingly, often a patient's diagnosis can be made from the historical information obtained by the doctor before a laboratory test is performed. Indeed, it is often drilled into medical students that a doctor can obtain a patient's diagnosis 80 percent of time just from the information that patient provides.

The patient does have a history of deep vein thrombosis, a type of blood clotting, in her medical history, and the patient did take an aspirin an hour before her dental surgery, this along with other factors make me suspect that the patient has a blood coagulation disorder possibly related to platelets.

After clicking the Continue button again I am presented with a diagram of the patient's body with red dots that when the cursor is placed over them give the results of the physical examination. While it is one thing to read about a patient's clinical findings in a computer simulated case scenario, it is much different to actually examen a patient and record the findings. I get a picture of the patient's bleeding gums. At least for this clinical scenario by using photographs it is easy to understand the pertinent physical exam findings for this case.

I then asked if the patient's disorder is more likely to be acquired or genetic, since she doesn't have a previous history of unusual bleeding, besides the episode 6 months earlier, I guess acquired. And I am told that this is "correct".

In summary, this clinical case scenario challenges the participant to select the best tests need for this patient, as well as to determine what the most likely diagnosis, and then final diagnosis is. This case scenario actually relies on the ability of the test taker to interpret a variety of clinical laboratory results to arrive at the correct diagnosis: surprisingly, multiple myeloma.

As the number of hours that resident doctors, or doctors in training, work per week has been drastically reduced, many residency programs are considering supplementing the clinical experience of their residents with similar simulated patient encounters, which could be done online, or even with life like robots, made to look like people, which mimic physical findings on a real patient.

Certainly the New England Journal of Medicine clinical case scenario seemed very educational, and such similar programs are likely to have great educational benefit for both doctors in training as well as more experienced doctors.

Sources:

New England Journal of Medicine
Interactive Medical Case
A Bloody Mystery
J.M. Connors M.D., K.A. Britton, M.D.
http://www.nejm.org