Teaching Motivational Interviewing with a Virtual Patient

 

 

 

 

by

 

William A. Villaume, Ph.D.

Associate Professor

 

Bruce A. Berger, Ph.D., R.Ph.

Full Professor

 

Bradford N. Barker, B.S.E.E.

Graduate Student

 

 

 

 

Department of Pharmacy Care Systems

128 Miller Hall

Harrison School of Pharmacy

Auburn University

Auburn, AL  36849
Table of Contents

 

 

 

Abstract:                                                   pg 3

 

Description of the Innovation:                              pg. 4

 

        Motivational Interviewing                    pg. 4

       

        Virtual Patients                                  pg. 6

 

        The Auburn University Virtual Patient   pg. 8

 

        Motivational Interviewing Assignment          pg. 11

 

Implementation of the VP Assignment  pg.  16

 

Evidence of Student Learning                               pg. 19

 

Evaluation                                                 pg. 39

 

Practicality/Workability/Transferability                pg. 40

 

Personal Reflections                                   pg. 41

 

References                                                 pg. 44

 

Teaching Motivational Interviewing with a Virtual Patient

 

 

Abstract

 

This portfolio describes the development of the Auburn University Virtual Patient that is currently working as a prototype.  High quality video files represent the patient’s comments and speech recognition is used to identify which of 2-5 possible responses was actually said by the student.  The program is run by a script that allows for multiple paths through the interaction.

 

A first year professional communication class was assigned to design and write the script for a Virtual Patient to allow students to practice Motivational Interviewing counseling techniques.  A sample student project is included.  Qualitative analysis of written student comments about the assignment indicated that 1) the project took too much time because of the complexities of the computer procedures deriving from the Virtual Patient being a prototype, and 2) the computer procedures deflected attention from the critical thinking involved in writing the script.  Quantitative item analysis of their final exam results indicated that they scored on the average one full letter grade better on the questions about Motivational Interviewing than on the questions covering other topics.  Apparently the students had learned more than they had realized.

 

The final section of the portfolio discusses improvements needed in the assignment and in the Virtual Patient program.  Further uses of the Auburn University Virtual Patient in other areas of pharmacy and healthcare education are discussed.


Teaching Motivational Interviewing with a Virtual Patient

 

                  

          Professional Communication (PYPC 5040) is a required first year course taught in Auburn University’s Harrison School of Pharmacy.  The primary focus of the course is to provide pharmacy students with an understanding and mastery of how to counsel patients about medications and lifestyle changes required by their treatment regimens. 

 

The early part of the course requires students to follow a patient counseling checklist in counseling a patient about a new prescription.  The checklist is explained using a lecture format with specific concepts illustrated by videotaped interaction and student-professor role playing.  Then in a major assignment the students role play a pharmacist counseling a patient presenting a prescription as specified in the assignment.  Each student submits a videotape of their role played counseling episode (enacted with another student or friend playing the role of patient), which is graded for whether the student has accomplished all the required counseling functions in a clear and accurate fashion. 

 

The later part of the course teaches Motivational Interviewing (see Miller & Rollnick, 2002) as the basis for more intensive patient counseling.  The emphasis is upon dealing with lack of treatment adherence resulting from patient ambivalence and resistance.  Several lectures and required readings are used to present the foundational concepts of I-You vs. I-It relationships (Buber, 1970), self-betrayal, self-justification and self-deception (Warner, 2001), stages of change in the Transtheoretical Model of Change (Prochaska & DiClemente, 1984), and the counseling strategies of Motivational Interviewing (Miller & Rollnick, 2002).  However, until the Fall 2004 semester, students were only tested upon this material in a multiple choice final exam.  There was no major assignment to allow students to struggle with how to implement Motivational Interviewing while counseling a specific patient.  There was no way for the students to experience how and why Motivational Interviewing leads to improved patient adherence.  In simplest terms, the students were presented with the conceptual foundations of Motivational Interviewing but did not practice how to use Motivational Interviewing. 

 

This portfolio focuses upon a pedagogical innovation that immerses students in using the principles and strategies of Motivational Interviewing to counsel a patient with a chronic medical condition in order to improve the patient’s treatment adherence.  This innovation invites students to consider what to say next in the utterance by utterance flow of an intensive counseling episode and then to experience how the interaction develops in either a productive or nonproductive fashion.  Essentially, we required groups of 2-4 students to write a script for a “Virtual Patient” program that the authors have developed as a working prototype.  Thus, there is an innovative class assignment nested within an innovative pedagogical tool for interaction skills training.

 

Motivational Interviewing

 

Motivational interviewing (MI) is an approach to improving adherence first reported in the addiction literature (Miller & Rollnick, 2002).  It is a process used to determine readiness to engage in a target behavior (taking a medicine as prescribed) in order to apply specific verbal skills and strategies based upon the patient’s level of readiness.  MI increases treatment adherence by stimulating or enhancing the patient’s intrinsic motivation in order to address and resolve ambivalence and resistance (major barriers to adherence) rather than by providing extrinsic motivation in the form of arguments, advice, and orders. 

MI is based upon the Transtheoretical Model of Change (TMC).  The transtheoretical model for behavior change targets common theoretical elements identified through the analysis of numerous therapy approaches (Prochaska & DiClemente, 1984).  The model provides a framework for understanding behavior change.  The model can help health care providers to understand various types of behavior change, as well help them to develop stage-specific interventions.  The majority of the empirical groundwork for the model derives from smoking cessation studies (DiClemente & Prochaska, 1982), but the model has also proven its value in addressing other health-related behaviors.  The model has been applied to smoking, weight control (Prochaska & DiClemente, 1985), psychological distress, alcohol abuse, exercise, and   psychiatric disorders (Prochaska, & Velicer, 1983).

 

The TMC has been used successfully to predict patient dropout from drug therapy (Berger, Hudmon, & Liang, 2004).  In a study of 531 patients, key transtheoretical model concepts (pros and cons of change) allowed for the successful prediction of dropout from the use of Avonex, a medication used for multiple sclerosis, in over 82% of the patients. 

 

Berger and colleagues used motivational interviewing to create software to be used by a pharmaceutical company’s call center to prevent dropout from drug therapy (Berger, et al, 2005).  Prior to the initiation of the software intervention, the company reported a dropout rate of nearly 13%.  The intervention was used for three months on a group of patients matched to a control group who received the usual level of care.  The dropout rate in the treatment group was 1.2% (N=169).  This was statistically significantly lower than the control group (p=0.001).

 

Motivational Interviewing uses a Menu of Strategies and five skills (Principles) to assess readiness to change and address ambivalence and resistance on the part of the patient.  The Menu of Strategies guides the “workup” of the patient to determine the patient’s understanding of the illness and its treatment and the patient’s understanding of how the drug therapy fits with the treatment goals.  In addition, the Menu of Strategies explores the patient’s lifestyle, a typical day, and the patient’s perception of the pros and cons of carrying out the treatment plan.  It is vital that the patient understand the benefits of the treatment plan and how to overcome any barriers.  The Menu of Strategies is comprehensive but does not need to be used with every patient since patients will vary in their readiness for and progression in managing their illness.

 

Five skills (Principles) are used within the Menu of Strategies to encourage change toward the target behaviors or treatment goals.  These skills form the acronym READS:

 

Roll with Resistance

Express Empathy

Avoid Argumentation

Develop Discrepancies

Support Self-efficacy.

 

          The Menu of Strategies and the Five Principles are the centerpieces for teaching Motivational Interviewing to students and health care providers.  In summary, motivational interviewing focuses on addressing ambivalence and resistance by using the Five Principles and assisting the patient in setting therapy goals that are meaningful to the patient.

 

Virtual Patients

                  

          Over the past decade, major advances in computer technology, visual graphics, and robotics have made virtual reality the cutting edge in the field of training.  For example, the media have acquainted us with the sophisticated simulators used to train commercial/military pilots, tank commander and drivers, etc.  In fact, commercial flight simulators have become so powerful in replicating the flight characteristics of a specific model of plane that there are paying customers on board the first time the pilot actually flies that aircraft. 

 

          Virtual reality is also being widely introduced into the training of health care providers.  The simplest form of virtual reality involves the conversion of paper based case studies into screen based case studies with hyperlinks to supplemental multimedia resources such as video files of the patient’s speech and behavior, audio files of the patient’s heart beat, visual files of X-ray and MRI results, and digital reproductions of lab reports.  More complex screen based case studies can implement a time line whereby the patient’s condition may change in the course of minutes, hours or days.  Time lines spanning years allow student health care providers to follow the progression of a patient from initial diagnosis through various treatments and even to death.  Experiencing the full progression of Parkinson’s or Alzheimer’s is usually not possible in a clinical setting.  Time lines also allow students to experience the impact of time lags between ordering diagnostic tests/treatments and receiving the results of such tests/treatments. 

 

More interactive screen based case studies employ complex scripts that allow students to follow a multitude of paths through the case depending upon the decisions made by the students in diagnosing and treating the patient.  In such case studies, the students can make serious mistakes without harming an actual patient.  Students learn more from experiencing the progressive worsening of a virtual patient’s condition to the point of death than from having a professor abruptly inform them that their decisions would kill the patient.  Furthermore, students can go back through such case studies to correct their mistakes and thereby experience varying degrees of improvement in the patient’s condition.  Such screen based case studies provide significant improvement in allowing students to practice clinical problem solving prior to the start of clinical rotations.

 

The most sophisticated use of virtual reality occurs when the pedagogical goal is primarily focused upon the mastery of physical knowledge, observation and/or manipulation.  For example, there are virtual patients using sophisticated 3D computer graphics to allow students to virtually dissect a variety of patients.  When combined with peripheral devices that provide visual, auditory and kinesthetic feedback, virtual patients can allow students to practice resuscitation techniques and surgical procedures.  For example, emergency room procedures can be practiced in a virtual environment experienced through a head mounted display (equipped with headphones and a microphone) and virtual reality gloves. The greatest sophistication is achieved when feedback is presented through life sized physical mockups of machinery and through robotic patients, such as when training personnel to perform any type of electronically mediated procedure, e.g. robotic surgery. 

 

The most problematic use of virtual reality occurs in the context of teaching verbal interaction skills such as counseling techniques.  There are a number of reasons for why it is difficult to construct realistic virtual people in order for computers to simulate face to face human interaction. 

 

1.   While speech recognition engines have achieved remarkable accuracy in converting speech to text (especially when trained for a specific user’s voice), the conversion is still happening on a literal level with little consideration of intended meaning.  Nonproprietary semantically driven natural language processing is still 5-15 years in the future – except in very restricted content domains.

 

2.   Speech recognition engines are unable to interpret indirect meaning that is not literally encoded in speech.  There are inference engines capable of inferring some indirect meaning but they require huge databases of background knowledge and hence are quite slow to run on even the most powerful personal computers.  In addition, these inference engines cannot compute all the conversational inferences that humans routinely and tacitly make during conversation.

 

3.   While human speech coordinates one major verbal code (language) with several nonverbal codes (such as facial expressions, gestures, body posture, emotional vocal tones, intonation patterns, word stress, etc.), advanced speech recognition engines have only the crudest ability to detect emotions (mostly from word cues rather than from nonverbal cues).

 

4.   Computer generated responses by a virtual human can be achieved only through the playback of previously recorded audio or video files, or through computer generated avatars (i.e., graphic cartoon-like characters).  Previously recorded video files display the verbal and nonverbal richness of human speech but are predetermined in content.  Computer generated responses spoken by avatars are quite flexible in content but poor in mimicking the verbal and nonverbal richness of human speech.  Even the best avatars (that synchronize lip movement and emotional facial expressions with the spoken words) still look and sound unnatural.

 

The most well known early attempt to create a virtual counselor was ELIZA, which was programmed more than 35 years ago for the mainframe computer to simulate the counseling techniques of nondirective Rogerian psychotherapy. ELIZA succeeded because the interaction occurred solely through keyboard input and screen displayed textual output. Furthermore, the nondirective technique of Rogerian Psychotherapy allowed for relatively simple parsing of input through the use of keywords to achieve either an adequate rephrasing or reflection of the patient’s input or a simple gloss around any interpretational problem.  For example, if the patient typed in “I get really irritated when I talk with my father”, ELIZA might respond with “It’s difficult for you to talk with your father” or “Tell me more about your father” or “Your father?” 

 

Several virtual patients have been developed during the past 10-15 years.  Generally they can be divided into three classes.  The first class employs a restricted set of questions that the student HCP can ask the patient by clicking on the text of the question.  For each question there is a digital video file of the patient answering the question.  Each question/answer set is independent so that the questions can be asked in any order.  Consequently, there is no interconnected flow to the virtual interaction.  Included in this class of virtual patients are the PsyIMM (Psychosocial Aspects of Bioterrorism Interactive Multimedia Module;  Triola, Feldman, Kachur, Holloway, & Friedman, 2004), the commercially marketed DxR (Diagnostic Reasoning Program; Bryce, King, Graebner, & Myers, 1998), and the ISP (Interactive Simulated Patient; Bergin & Fors, 2002). 

 

The second class of virtual patients also uses a restricted set of responses from which the students select.  However, these responses are scripted to simulate the flow of natural interaction.  Typically, the patient’s comment is played in a video window followed by a menu of possible responses for the student.  After the student selects a response, the program selects the proper video file to be played as the patient’s next utterance.  With careful scripting the interaction can grow in a coherent and dynamic fashion.  In other words, the interaction is dynamic insofar as the course of interaction is determined by the sequence of decisions made by the student.  Representative of this class is the Heart of the Problem Virtual Patient (Bearman, 2003) in which students choose their response by clicking on the text of the response displayed on the screen, and the Virtual Conversations for STD/HIV Risk Assessment program (http://idrama.com/HIVseries.htm ; accessed on Jan 10, 2005) which appears to use a propriety engine to identify which choice was spoken by student users (Note: the exact interface and mechanism of speech recognition are not clear on this website). 

 

The final class of virtual patients emphasizes the flexible dynamic development of virtual interaction by allowing for free form spoken input by the student and then by using a smart emotive avatar to represent the patient instead of playing a fixed video.  The advantage of an avatar is that the computer can strategically determine at runtime the exact wording of the patient’s response in light of what has happened previously in the interaction.  Then a text to speech engine and an emotive behavior engine generate the audio and graphics required for the avatar to speak these words on screen.  This class of virtual patients is an implementation of RTI’s more general approach to training via avatars programmed with AVAtalk (Hubal, Kizakevish, Guinn, Merino, & West, nd;  Hubal, Frank, & Guinn, 2003; Link, Armsby, Hubal, & Guinn, 2002).  The programming involved is extensive because it involves a speech recognition engine, a semantic/pragmatic interpreter, a response strategy selector, a text to speech engine and an emotive behavior engine.  While the dynamism of the interaction is improved, the richness of the patient response is decreased because of the constrained artificial behavior of the avatar.  Also the realistic timing of the interaction is lost because the increased computer processing time slows down the virtual patient’s response time.

 

The Auburn University Virtual Patient

 

The Auburn University Virtual Patient (AUVP) is currently being developed in the Department of Pharmacy Care Systems of Auburn University’s Harrison School of Pharmacy.  The basic goal was to use the AUVP to give P1 students in the Professional Communication class a chance 1) to experience the difference in patient reactions to traditional biomedical counseling vs. Motivational Interviewing (MI), and 2) to practice using Motivational Interviewing principles and strategies.  The following characteristics were deemed necessary for the AUVP to achieve these goals.

 

1.   A restricted set of responses was appropriate for students who are new to using MI and need some guidance.

 

2.   The script should be written to allow for the dynamic and coherent development of several paths through the interaction.  In other words, student responses should affect the subsequent flow of the interaction.

 

3.   The students should actually say their chosen responses to improve multisensory learning and to allow for the recording of their responses so that the whole counseling episode might be replayed.

 

4.   The patient’s utterances should be represented by the playback of high quality video that allows the students to perceive the rich nonverbal aspects of the patient’s message.

 

 

 

The Auburn University Virtual Patient, programmed for Windows computers by the third author in Visual Basic 6.0 SP2, relies upon Microsoft’s SAPI 5.1 for its speech recognition engine and upon Microsoft’s Windows Media Player 9.0 to play high quality video of patient responses portrayed by an actor.  The scripted interaction is divided into a series of “states” consisting of a patient utterance followed by the student’s response.  When the interaction progresses to a new state, the digital video of the patient’s utterance is played first.  Then 2-5 possible responses are displayed on the screen for the student HCP to select from.  Instead of clicking to select a response, the student actually says the selected response. The speech recognition program then processes the student’s voice to identify which response was said.  Minor variations in wording are usually accommodated.  When the student has finished speaking, within 1-2 seconds the program starts playing the proper video file containing the patient’s response.  If there are 5 possible utterances for the student to choose from, there can be up to 5 different patient responses specified, i.e., one for each possible student choice.  With such branching capabilities, AUVP scripts can easily offer a complex variety of paths through the virtual counseling session. 

 

At this point it would be helpful to see the AUVP in operation.  Please play the Windows Media file AUVP_video.wmv on the accompanying CD.  If you do not have version 9 or 10 of Windows Media Player installed on a Windows computer, you will have to install version 10 from http://www.microsoft.com/windows/windowsmedia/mp10/ads.aspx .  We have provided a video of the AUVP in operation in order to avoid the somewhat buggy character of the installer for the prototype AUVP.  The video demonstrates three paths through an initial segment of a counseling episode with a patient who has hypercholesteremia and has been noncompliant with his low fat diet.  The first path is the pure MI track, the second is the pure BM track and the third involves a mistake and a recovery from the mistake (whereby the student starts on the MI track, moves to the BM track and then recovers back to the MI track).  

 

The AUVP program is run by a script.ini file that stores the information required to process each possible state in the interaction.  The information fields for a typical state would look as follows:

 

[S11]           

Patient = "Hey.  That Flovent didn't work."

Video = S11.wmv

Choice1 = "It’s frustrating when your medicine doesn’t work.  What happened?"

Action1 = S12

Choice2 = "Did you take it every day as prescribed?"

Action2 = S112

 

Other choices would be indicated with the optional fields Choice3, Action3, Choice4, Action4, Choice5, Action5.  The Patient field specifies what the patient says in the Windows Media file specified in the Video field.  The two possible student responses are listed in the fields labeled Choice1 and Choice2.  The Action fields specify the destination state associated with each Choice field.

 

If the action field of a prior state has specified that the computer advance to S11, the computer reads in the values of these fields.  Then the video file S11.wmv is played and the two choices are displayed on the screen.  When the speech recognition engine has determined which Choice was spoken, the computer advances to the state specified in the associated Action field.  In this example state (S11), if the student says Choice1, the program advances to state S12.  If the student says Choice2, the program advances to state S112.  Thus, this state serves as a simple branching point in the script and allows the progression of the interaction to reflect what the student has chosen to say.  In this example, Choice1 represents a Motivational Interviewing (MI) response and directs the computer to state S12 which initiates a cooperative sequence of interaction.  Choice2, on the other hand, represents the biomedical (BM) approach in counseling and leads to state S112, which initiates a series of states in which the patient becomes increasingly defensive and resistant.  Thus, the student HCP can experience how patients open up in response to MI responses and close down in response to BM responses.  Subsequent states can incorporate choices that allow a student to recover from a BM response by selecting a MI response.  The easiest way to track the branching operations in the script is to create a path diagram as in the following figure:

 


                                            MI                                   BM

                                          Track                               Track

 

 

 


                                                              S11              

 

                                          S12                                  S112

 

 


                                          S13                                

                                                                                S113

 


                                          S14                                

 


                                                                                  S114

                                          S15               

 


                                                           

                                                              S16                            

 

 

 

          The most critical aspect of writing such scripts for the AUVP is to ensure than any patient utterance and any student choice makes coherent sense regardless of the interactional path leading up to that utterance.  For example, if you are writing the patient and choice fields for S14 above, they must make sense for the five following paths:

 

                   S11   S12     S13

                   S11   S12     S112   S13

                   S11   S12     S112   S113   S13

                   S11   S112   S13

                   S11   S112   S113   S13

 

As the length of a script increases, the number of possible paths through the interaction quickly increases and it becomes difficult to read through the text for each path in a word processor.  Therefore, an Authorware program was written to compute all the possible paths for a script and to check for possible loops.  In addition, if the script author clicks on any path, the program assembles the script for that path in an easily read format.  At this point, if you wish to view the interface of the authoring program and to see how it works, please open the PowerPoint files VP_Authoring_Instructions.ppt and VP_Authoring_Instructions.ppt on the accompanying CD. 

 

Motivational Interviewing Assignment

 

Ultimately the AUVP is to be used in the Professional Communication course by assigning the students to work through several Virtual Patients immediately upon the conclusion of the class lectures on Motivational Interviewing.  Subsequent assessment of their mastery of Motivational Interviewing would employ standardized patients in a face to face context.  However, because the AUVP is still in the prototype stage, such Virtual Patients had yet to be produced with full scripts and high quality video of the patient. Therefore we decided to assign to the students the task of writing a script for the AUVP.  We felt that such an assignment would require the students to consider how they would use MI techniques on an utterance by utterance basis with a particular patient.  While the techniques of MI are theoretically understandable, using these techniques in individual utterances requires a considerable adjustment of vocabulary, grammar, emotional tone, and rhetorical strategy.  Trying to work through these adjustments in real time with a standardized patient is very difficult.  Considering and refining these adjustments in the course of writing a script is much easier.  The writing process also allows the students to assess how the interaction develops in the various paths through their script.  

 

Please refer to the AU Virtual Patient Assignment on the next page.  The students were given five weeks to complete the assignment.  They arranged their own groups of two to four students.  Of the 34 groups in the class, only one was assembled by the professor from individuals.  Several requests for 5 person groups were denied. 

 

The groups were assigned to one of six disease states:  arthritis, asthma, Type II diabetes, GERD, hypertension and osteoporosis.  Each group submitted their top three choices for a disease state.  All groups were assigned to one of their top three disease states. 

 

 

 

 

 

 

 


PYPC 5040   Fall Semester 2004

Virtual Patient Assignment

 

Your small group of two to four members will write a script (for the AU Virtual Patient Program) simulating the process of counseling a patient. You will be given a description of a patient, his/her disease state and the medications prescribed by the physician.  You will write a script allowing a student pharmacist to explore and practice the techniques of Motivational Interviewing while counseling this patient.  The assignment consists of two major parts. First, you will write an 8-10 page rationale for the goals and strategies of your Virtual Patient program.  Secondly, you will write a script allowing the student pharmacist to interact with the Virtual Patient in at least three different modes:

a. strictly Bio-Medical mode

b. strictly Motivational Interviewing mode

c. a mix of the two modes

 

This assignment is worth 20% of your final grade.  The assignment is due at the start of class on Tuesday Dec. 7.

 The AU Virtual Patient program uses digital video/audio and speech recognition technologies in order to allow a student pharmacist to engage in a computer simulated counseling session with a patient. The patient is presented on screen using digital video (or just vocally using digital audio). The computer “guides” the pharmacist’s responses by displaying on screen the text of 1-5 possible responses.  The student pharmacist then says their chosen response.  The computer uses a microphone and speech recognition to determine which response was said and then plays the digital video or audio of the patient’s next utterance. Because each response by the student pharmacist may occasion a different next utterance by the patient, there are many different paths through the interaction with the Virtual Patient.  To assist in writing this script, you will be provided a special authoring program (for entering data and tracking all the possible paths through the script) and a fully operational example of a Virtual Patient (with full audio/video and the script file running the VP program). 

 

This example Virtual Patient is a 57 YOWM with recently diagnosed hyperlipidemia.  He has just come in for his first refill of a prescription for Lipitor 20 mg. QID.

 

 

Background and Rationale for your Virtual Patient

 

1.     Identify the major reasons patients do not effectively treat their illness.

*     Why doesn’t this disease get treated properly (assuming appropriate choice of therapy)?

*     What are the major causes of noncompliance with treatment regimens (including drugs and life style changes) for this disease state?

*     How do these forms of noncompliance affect treatment outcomes for this disease state?

Your paper must provide adequate justification for the choices enacted in the script.

 

2.   Generate a detailed profile of the medical and social history of this particular patient.  In this step you are “fleshing out” the individual character of your patient, much as an author would before writing the text of a play or novel.  Try to make your patient representative, realistic and interesting.

 

*     Avoid making your patient’s situation so simple that you unable to provide a rich learning experience for the student pharmacist.

*     On the other hand, don’t make your patient’s situation so complicated that a P1 student pharmacist would have extreme difficulty understanding various aspects of the patient’s treatment program. 

 

3.   Develop the top three priorities for counseling this patient.  Then make these priorities the basis for three short episodes in your scripted counseling session. 

 

In the example Virtual Patient with hyperlipidemia, the top three priorities for counseling are:  

properly taking the prescribed statin 

proper diet

proper exercise. 

 

Explain what cause(s) of noncompliance this patient will exhibit for each of these priorities and what strategy and tactics the patient and counselor will exhibit in the script for each of these episodes.  You are to script one of these three episodes as helping the patient to achieve full compliance for that component of treatment, a second episode as helping the patient to achieve partial compliance for another treatment component, and the third one with the patient not being ready to even consider compliance for the final treatment component. 

 

In the example Virtual Patient:

A.     The patient simply forgets to take his Lipitor 2-3 times a week and thinks nothing of it.  Helping the patient to understand how Lipitor works, and tailoring medication taking to his daily routine will leave the patient ready for full compliance in taking his medication. 

B.     The patient tried to follow his diet but gave up after 3 weeks when he needed “to have something good to eat”.  His family ritual of grilling out and tailgating is a major temptation that he solves by identifying the possibility of a new low fat specialty on his grilling menu.  The pharmacist doesn’t try to push compliance for all meals.  Rather a “seed” is planted suggesting that the same approach could work across all meals.  In this episode the patient is ready for partial compliance.

C.     The patient has been turned off by formal exercise early in life and prides himself on being a “couch potato”.  The pharmacist explores the meaning of exercise for the patient and then decides to create some dissonance and share an approach used by other “exercise haters”.  The patient will still be noncompliant but may have moved from precontemplation to contemplation.

 

 

Virtual Patient Module

 

4.     Your group’s computer expert will install the AU Virtual Patient on his/her computer (and if desired on the computers of other group members).  The computer should have a good microphone (either as part of the laptop or connected via USB or the serial microphone port) and SAPI 5 or 6 installed (in Microsoft Word, choose Tools, Speech).  It is a good idea to train the computer to recognize your voice.  Confirm that you can record speech in a .wav file using the Sound Recorder (Programs > Accessories > Entertainment).  In addition, you will install the Virtual Patient Authoring Program that allows you to enter the script in proper format and to view and read all possible paths through your script.  There is a PowerPoint file on WebCT that demonstrates how to use this authoring program.  In addition, all these techniques will be covered in a special training session for the computer experts on Thursday 11/4 immediately after class in Broun 238.  Be sure to bring your computers and microphones.  Bringing an additional group member to this session might be wise. 

 

5.   Write the script for your Virtual Patient using the Authoring Program.  When you are finished, be sure to add the final states S998 and S999 as in the example Virtual Patient script.  S999 automatically terminates the program.  S998 gives the option to start over or to exit the program.  Save your final script as Script.ini.  Open it up with Notepad and then copy and paste the whole script into an Appendix of the Microsoft Word file for your project. Document the relationship among the states with a flow chart as illustrated in the WebCT PowerPoint file for Instructions in using the Authoring Program.  Include a printout or Xerox of this flowchart as an Appendix to the paper.

 

6.   Record the patient’s utterances into .wav files (digital audio) using Sound Recorder.  Try to get a voice that matches your patient as well as possible.  At least have a female voice for a female patient, etc.  It’s hard to read exact text and make it sound alive and natural.  It would be easier if your actor can use some of his/her own words.  As long as the major ideas are those required for that utterance, everything is fine.  You should then go back into the script and change the words to match what was actually said.  Do NOT have too much silence at the beginning of the file or the end of the file.  That would increase the lag time before the patient responds in the Virtual Patient program.  Copy the .wav files into the Multimedia subdirectory.  Copy your script into the main directory where the Virtual Patient program resides.  You should then be able to run your Virtual Patient with audio files.

 

7.   Print out your paper with background information for the disease state and rationale for the script.  Cite supporting sources and include them in a reference list using AMA style guide (http://healthlinks.washington.edu/hsl/styleguides/ama.html).  Print out the two appendices (script and flowchart).  Burn the Word file, the script.ini file and the Multimedia subdirectory (with the audio files in it) to a CD.  Also burn a text file called Group##Info.txt to the CD.  This file should contain full information about the group such as group number, names of the members, the disease state and patient info assigned, and any special notes needed to understand your project)  Label the CD as “VP Group ##  11/18/04”.  Check to see that this CD will read on other Windows computers.  Be sure to burn backup copies of this CD.  Put all material in a large Manila envelope sealed with a metal clasp and labeled with your group number and members’ names.

 

8.   The assignment is due at the beginning of class on Tuesday Dec 9.  There will be no lab sections on Nov. 9 and 11 so that you will have time to work on this project. Additional class time may be provided later.

 

9.   If you have any questions about technical details in using the programs or basic questions about Motivational Interviewing, please contact Dr. Villaume by e-mail or phone (844-5818).  He will also be available in his office for consultation as posted next to his office door (141 Miller Hall).  For more complex questions about Motivational Interviewing and about disease state and medication topics, please contact Dr. Berger by e-mail or phone (844-8302). 

 

 


 

Implementation of the VP Assignment

 

Given the complexity of the computer procedures involved in installing Microsoft SAPI 5.1, Windows Media Player 9 or 10, the Authorware authoring program, and the AUVP program itself, each group sent a designated computer expert for special training.  It turned out that several training sessions were required over the span of the first two weeks of the assignment.  In addition, the first author was available most class days for consultation in his office.  Such individual consultations were often necessary to overcome small computer glitches deriving from problems with the operating system, options being turned off in SAPI, and bugs in the prototype AUVP programming.  Most of these problems were corrected by the end of the third week, except for groups that had postponed the assignment until the end.  Major corrections were handled by reprogramming the AUVP program to correct several glitches (such as implementing word wrap for longer choices displayed on screen), compiling a list of required settings for SAPI, and by using a computer belonging to a different member of the group.  Problems in understanding the format of the script file was handled by putting together a second PowerPoint file to address these problems. 

 

During the last week and a half computer problems centered around two issues: problems with audio files representing the patient, and debugging the script files.  Sound problems generally involved a volume control deep in the operating system being turned down very low or even muted, so that the audio would not record or would not playback in an audible fashion.  In a number of cases, lavaliere microphones were not of sufficient quality to run the speech recognition portion of the AUVP program.  A simple $10 microphone from Wal-Mart corrected the problem.  The debugging problems resulted from the fact that most students had written the script in Notepad or Word.  Then they tried to load the script into the authoring program to check out the paths.  Often the script would not load because of some minor problem, such as using a colon where there should have been an equals sign, e.g., Choice1:  Would you please ... instead of Choice1 = Would you please …  Debugging such mistakes proved to be very difficult for most students who did not understand how literal computers are in following programming.  Most of these glitches were corrected during the last 4-5 days.  In the case of irresolvable problems in running the script in the AUVP on a few individual computers, the first author either made sure that the script would run on his office machine, or noted the problem so that an appropriate accommodation could be made in grading the assignment. 

 

All through the assignment, e-mails were sent out to every student in the class listing any identified computer problems and how to correct them.  Many students never read these e-mails and preferred to come directly to the first author.  The same thing happened with the two PowerPoint files giving authoring instructions.  They had been sent out to every student as e-mail attachments and were also available on WebCT for download.  Students seemed to feel that they were too busy to consult these resources and wanted their problems corrected immediately. 

 

Extensive consultation was also provided by the second author with regard to the content of the scripts.  While most student groups had no problems in formulating the patient’s utterances and the choices representing the BM approach, most groups had some difficulties formulating utterances that represented high quality MI responses.  Consequently the second author provided extensive consultation about writing good MI responses.  He generally found that he could review their scripts from a simple printout of the script file rather than from having to load the script into the authoring program on a computer.  Most major problems in writing MI responses revolved around implementing the basic principles of MI as previously described.  In essence, these problems represented the pedagogical heart of the assignment as is evident in the following examples.

 

1.   Students were using closed ended responses allowing for the patient to answer Yes or No rather than using open ended responses prompting the patient to elaborate.  “Are you taking your medication properly?” needed to be changed to “Tell me how you are taking your medication.”

 

2.   There were problems formulating empathic responses that reflected the patient’s emotional state and the heart of the issue.  If the patient said “I really hate the idea of having to take medication to stay healthy”, a response of “You don’t like taking medication” needed to be improved to “Being dependent on medication really bothers you.” 

 

3.   Empathic statements were often followed by negative criticism implicit in such conjunctions as “but”.   For example, “I’m proud of how you have avoided pigging out at buffets, but you still need to …” was changed to “I’m proud of how you have avoided pigging out at buffets.  Tell me how you think you could further improve your diet.”

 

4.   Students had difficulty writing responses to highly resistant comments such as “When are you folks going to stop pestering me about smoking?”  The tendency was to engage in argumentation about the importance of stopping smoking.  Students needed assistance in wording a more nonargumentative approach that created dissonance in the patient:  “It sounds like you aren’t ready to stop smoking.  I want you to know that if you change your mind, there are several ways that I could be of assistance to you.  I am really concerned about what can happen to your emphysema if you continue to smoke.”

 

5.   Many scripts avoided probing decisional balance with regard to how the patient perceived the pros vs. cons of following the prescribed treatment plan.  Students had to be prompted to use a readiness ruler or envelope to determine what might tip the decisional balance in favor of greater compliance. 

 

6.   Students tended to be somewhat wordy in writing MI responses.  Two to three pharmacist responses could often be condensed down to one, thereby saving several seconds.  For example, if a patient said he was having difficulty remembering to take his medicine on time, the students might have the pharmacist saying “It is difficult to remember to take this medicine on time.” If the patient then failed to elaborate by simply saying “Yeah, it’s tough”, the pharmacist had to follow up with a question such as “What difficulties were you having in remembering to take it on time?”  It’s quicker to initially say “It is difficult to remember to take this medicine on time.  Tell me about what made it hard for you to remember.”

 

 

In order to provide easy access to consultation, two class periods were devoted to consultation during the week prior to the due date for the assignment.  The first author met in the front of the classroom with students having computer problems and the second author met at the back with students needing feedback about MI responses.  These sessions led to considerable discussion among the groups about MI.  In fact, students from different groups were spotted several times in the halls and study areas discussing their scripts.  During the last class of the semester, when the assignments were handed in, the second author led a spirited discussion of how to use MI in responding to difficult situations with patients.  Many of these situations had come from nurse case managers phoning patients with serious chronic conditions. 

 

Grading the assignments was handled solely by the first author.  The initial plan had been to have the assignments graded by two GTAs, who had already been trained.  However, all the projects were graded by the first author because he was the only one who knew which computer problems were irresolvable and which problems could have been avoided.  The grade distribution was:   21 As,  9 Bs,  1 C,  and  3Ds.   The numerical scores for individual aspects of the project were supplemented by comments keyed to specific sections of the paper and the script, and by a final summary evaluation.  It took from 30 to 45 minutes to grade each project.  Some of the outstanding projects had complex scripts that went well beyond the minimum requirements.  One script was so complex that the program was still computing possible paths after five minutes when usually it took from 5-15 seconds to identify up to 100-200 paths.  The grader examined only three paths in detail:  the pure MI path, the pure BM path, and the path including all the mistakes and recoveries. 

 

Lower grades were easily attributable to several causes.  First, some groups were sloppy in assembling the final project packet.  At least two groups fell from an A to a B because they failed to include the first two pages of the paper or the required path diagram.  Second, some groups had divided the work into independent sections assigned to individuals with no coordination of among individuals.  So an outstanding paper might be followed by a poor script.  Third, the groups receiving Ds had avoided consultation with the second author about the content of their scripts even though they had been advised to do so by the first author.  They seemed to have regarded the assignment as a mechanical exercise in producing a script and had failed to realize that the pedagogical challenge was to implement MI in the script.

 

The next section is composed of a sample packet submitted by a group focusing on osteoporosis plus the grading form returned to them.  This project received the highest grade in the class and consequently is an example of what may be achieved in this assignment. 

 

 

 

 

 


Note about our Virtual Patient Project

 

Group 1

 

Asthma

 

Our patient is Lucy, a 16 year old female, diagnosed with asthma.  She was prescribed Flovent and Albuterol. She was instructed to maintain a peak flow diary to monitor her asthma.

 

 

During our final touch-up of the script, we realized that we needed to expand some of the scenes in episode 1.  Instead of renumbering all of the states, we inserted states S40 and S41 as needed.  This is should be easy to follow using the diagram attached in the Word document.

 

 


Virtual Patient Project – Group 1

Asthma

Asthma is a common medical problem that affects approximately 6.4 percent of the American population today.  It is a chronic problem that requires continual adherence by the patient and optimal interaction with health care providers.   Through a general understanding of asthma, risk factors of the disease, and a detailed comprehension of the basic forms of noncompliance, one is able to develop a plausible virtual patient that pharmacists and other care providers can use to strengthen communicative interactions with patients.

 

          The condition of asthma is a chronic inflammatory lung disease characterized by recurrent breathing problems.  The main cause of asthma is virtually unknown; however, healthcare professionals have determined that it is a unique inflammation of the airway that can lead to contraction of airway muscles, mucus production, and swelling of the airways.  There are several triggers that can induce an asthma attack, but emotional factors, such as anxiety and stress, are ruled out as being a direct cause.  However, these emotional factors can indirectly affect the immune system and thus increase symptoms. 

 

There are two main components of asthma that occur deep within the airways: inflammation and constriction.  During inflammation, swelling and irritation occurs in the airways and can result in an attack, thus reducing the amount of air that the patient can take in or breathe out of the lungs. In constriction, the muscles surrounding the airways squeeze together and tighten.  This phenomenon is termed “bronchoconstriction” and can result in difficulty breathing air in and out of lungs.  Together, these two components can lead to hyperresponsiveness, wheezing, shortness of breath, and tightening of the chest.  The seriousness of these symptoms can make it immensely difficult for a patient suffering from this disorder to maintain a normal and active lifestyle. 

 

One of the most severe side effects of asthma is an acute episode known as an asthma attack.  It is basically caused by oversensitivity of the lungs to various triggers.   During an attack, passages in the lungs get narrower and breathing becomes significantly more difficult.  When a patient is experiencing an asthma attack, breathing becomes harder and may hurt, coughing can occur, and a whistling sound known as wheezing typically occurs.  Wheezing results from a rush of air through narrowed airways that are further blocked with mucus.

         

Triggers of asthma often vary based on the individual and his or her response to environmental stimuli.  It is necessary for patients to attempt to identify and remove any known triggers from their environment, and such identification and avoidance should be an integral part of the treatment plan.  These triggers can include: smoke and other strong odors, dust, pollen, indoor and outdoor mold, pets and other insects, exercise, and winter colds and infections.  First of all, patients should completely avoid smoking and should avoid any areas that may contain smoke. This includes in the home or any enclosed space, such as a car or restaurant.  Also, strong odors such as hairspray, perfume, and paints can also induce attacks, and patients should be advised to avoid any products with a volatile odor.  Secondly, problems with dust, pollen, and other molds can pose a problem with asthmatic patients.  Dust mites are tiny bugs that live inside cloth and carpet, and special care must be taken to minimize negative effects, such as replacing old pillows and replacing carpet with hardwood floors.  During allergy season, pollen and outdoor mold can also become a hindrance for patients dealing with asthma.  Staying indoors with the windows closed or adjusting a current asthma regimen may be necessary to alleviate symptoms.  Furthermore, pets and other insects can intensify symptoms due to an allergy of some asthmatic patients to the flakes of animal skin or dried saliva from certain animals with fur or feathers. Also, many birds produce feather dust that is a non-allergic trigger.  In this instance, patients should be advised to either find a new home for their pet or keep the pet out of bedrooms and other rooms with carpet and furniture.  Patients with asthma are also commonly allergic to dried droppings and remains of insects, such as cockroaches.  If a spray is used to kill the insect, the patient must be instructed to stay out of the room.  Next, patients with well-controlled asthma are encouraged to remain as active as possible, but special precautions must be taken so as not to set off symptoms.  For example, the patient may be advised to warm up for about ten minutes before exercise by stretching or walking and to avoid outdoor exercise when air pollution levels are high.  Finally, cold weather and associated illnesses, such as colds and infections, can trigger asthma and aggravate symptoms.  The patient should be counseled and informed about adequate precautions, such as receiving a yearly flu shot, getting plenty of rest, drinking fluids, and wearing warm clothing when going outside.  By sufficiently educating patients and using effective counseling methods, health care providers are able to help asthma patients live a more fulfilling life by avoiding these triggers and minimizing negative symptoms.

         

The incidence of acute asthma is continuously increasing in the United States and is associated specifically with certain risk factors, such as age, race, and gender.  According to the National Heart, Lung, and Blood Institute, about 15 million people suffer from asthma, including 5 million children.  Asthma is more prevalent in children than in adults, and is more common in male children than females.  In children younger than ten years old, the male to female ratio is 2:1.  In contrast, the ratio is reversed in adults, with females much more likely to suffer from asthma as men.  For example, women are twice as likely to be hospitalized from acute asthma as men, and studies have shown that forty percent of these hospitalizations occur during the premenstrual phase of the menstrual cycle.  This indicates that the menstrual cycle may be a possible triggering factor for adult women.  In addition, asthma is about eight percent more common in the African American and Hispanic population than in Caucasians.  Also, African Americans are four to six times more likely to die from asthma than Caucasians.  This may be due to the lower socioeconomic conditions of these groups.

 

          When it comes to taking asthma medication, there are many ways that people may be non-compliant. In general, asthma patients usually have medicines that must be taken daily and medicines that are only taken during episodes. One of the most common forms of non-compliance is for patients not to take their daily medicine when they are feeling well. Many patients just simply forget. Also, some may not realize how serious the symptoms of asthma can affect their lives. This can be a life threatening form of non-compliance that should be given special attention by the pharmacist.  In addition, many patients are reluctant to remove triggers from their homes.  Certain lifestyle changes, such as finding a new home for a pet or smoking cessation, can be very difficult for the patient, and he or she may need extra time to move through the stages of change.  For example, many asthma patients, especially young children and adolescents, may be apprehensive about other people knowing that they use an inhaler and may try to avoid using it in public places. All of these reasons can lead to a person being non-compliant and can be potential life threatening decisions.  It is vital for pharmacists and other health care providers to use effective interviewing techniques to determine the underlying issues that lead to the asthma patient’s non-compliance. Then, the patient needs to be encouraged to make decisions that will be beneficial to his or her mental and physical wellbeing.

 

          When developing a treatment plan for asthma patients, the choice of regimen varies based on the severity of the condition.  However, it is first important to understand the general types of medicine that can be given in each stage.  Basically, patients are on two types of medicines: long-term (preventative) medications and quick- relief (rescue) medications.  Preventative medications are used to help prevent symptoms from occurring in the first place. The most common long-term medication is inhaled corticosteroids (ICS). The National Institute of Health recommends ICS as the preferred initial therapy to treat persistent asthma. Inhaled corticosteroids work by reducing inflammation of the airways. This reduction can improve lung function, prevent asthma symptoms, minimize long-term lung damage potential, and minimize reliance on a quick-relief inhaler. Inhaled corticosteroids are an excellent choice in treating asthma because they go right to the needed site of action. This causes a smaller risk of side effects when compared to a pill that must travel throughout the bloodstream. To help prevent symptoms, ICS must be taken everyday, even when patient is feeling well.  In addition, long-acting beta2- agonists are a preferred long-term medication that work as bronchodilators by relaxing the smooth muscle surrounding the airways and helps to keep them open. However, these are only to be used as a compliment to inhaled corticosteroids.  Quick-relief medications generally work to stop tightening of the muscles during an attack.  Some may be found in pill form, but are most commonly inhaled.  Short-acting beta2 agonists relax muscles within minutes to relieve attack symptoms caused by triggers. Sometimes a patient that has minimal, occasional asthma may only be prescribed a short-acting medication. However, if the patient has to use his or her short-acting medication more than twice a week, this is a sign that the asthma condition may not be under control and further medications may be necessary.  Also, systemic corticosteroids can be used to reverse the inflammation and speed recovery from an attack, which aids in preventing future attacks.

 

          Asthma patients generally fall into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Each of these categories has a different treatment plan.  Mild intermittent patients have symptoms less than two days per week and less than two nights per month. No daily medication is needed to treat patients with mild intermittent. However, a short-acting medication and a course of systemic corticosteroids are recommended to treat those patients.  If a patient has symptoms greater than twice a week but less that one time per day and greater than two nights per month, he or she is considered to be in the mild persistent stage.  The preferred treatment for this stage is a daily dose of low-dose inhaled corticosteroids. If a patient is considered to have moderate persistent asthma, he or she will exhibit symptoms daily and greater than one night per week. The preferred treatment is low- to- medium dose inhaled corticosteroids and long- acting inhaled beta2 agonists taken daily.  Finally, the most severe stage of asthma, severe persistent, is characterized by continual symptoms during the day and frequent symptoms at night.  The daily preferred medication regimen is high-dose inhaled corticosteroids and long-acting inhaled beta2-agonists. Also, corticosteroid tablets or serum can be taken if needed. It is imperative that all of the above medications be taken daily with full compliance in order to be effective. However, all patients need a quick-relief medication available. The most common is a short-acting bronchodilator. Two to four puffs are generally prescribed depending on the severity of the symptoms. Furthermore, systemic corticorsteroids may also be needed to further minimize negative effects. It should be noted that if short-acting beta2-agaonists are used more than twice a week, this may indicate that changes in long-term medications may be required.

 

          In addition to medications, other equipment is also used to help monitor and treat asthma.  First of all, peak flow monitoring is a very useful tool in determining lung function. Peak flow meters work by measuring the fastest speed in which a person can blow air out of the lungs.  Changes in the asthma patient’s peak flow reading can indicate a possible oncoming attack. Also, peak flow monitoring is used to evaluate how well the disease is being controlled.  Secondly, spirometry may be used by a physician to evaluate lung function. Through the use of a spirometer and simple pulmonary function tests, the physician can determine how well the lungs receive, hold, and utilize air. This is vitally important in the management of asthma. The physician may also require blood tests to monitor the amount of carbon dioxide and oxygen in blood, allergy tests, and chest x-rays.

 

          Regardless of the level of disease management, asthma control has six basic goals of therapy as defined by National Asthma Education and Prevention Program. The first three goals are for the patient to have minimal or no chronic symptoms day or night, minimal or no exacerbations, and no limitations on activities.  The forth goal is to maintain near normal pulmonary function. Goal five is the minimal use of short-acting inhaled beta2-agonists. Finally, minimal or no adverse effects from medications is considered a fundamental part of optimal asthma control.

 

          It is necessary that the characteristics and background of our virtual patient be fully understood so the pharmacist’s interaction with the patient can be fully maximized. Lucy Adams is a sixteen-year-old female with mild persistent asthma.  She has symptoms more than twice a week, but less than once a day and nighttime symptoms more than twice a month. She also has more severe episodes that sometimes will affect activity. Lucy takes an inhaled corticosteroid (Flovent 110 mcg every day) and a short-acting beta2- agonist (Albuterol 2 puffs every 4-6 hours as needed). She was counseled by a pharmacist and is aware that she is supposed to take the Flovent every day, even if she feels fine. She knows not to change the dosage amount and to keep taking her medicine even when she has an attack. Lucy was educated to keep her inhaler (Albuterol) with her and to frequently check it to make sure it still has medication in it. The pharmacist empathized that having asthma can be a drag, but that is can also be something that she may rarely have to worry about.  She was further encouraged not to limit herself by staying away from activities that might induce an asthma attack.

 

          Lucy is generally non-compliant in three areas of her treatment program. First, Lucy stopped taking her Flovent after four weeks because she had a flare-up while jogging during physical education at school. Lucy assumed that because she was taking Flovent, she would never have another flare-up. When she did have a problem, she assumed that the Flovent was not working properly, and she stopped taking it.  Next, Lucy has not been consistently monitoring her asthma with a peak flow meter because she believes that it is a pain and is not important. She claims that on mornings when she feels good, she doesn’t even think about using it. The last form of Lucy’s non-compliance is her brother’s pet cockatiel that is allowed to fly around the house when he is home.  Asthma patients should not have birds as pets because the feather dust produced by all birds is a non-allergic cause of bronchial irritation and inflammation, and thus can have negative effects on Lucy’s asthma. However, Lucy does not want her illness to affect her brother and refuses to talk to him about keeping the bird in his room. These three forms of non-compliance will form the basis of the three episodes discussed with the virtual patient.

 

          Episode one focuses on Lucy taking her Flovent properly. The pharmacist must explore Lucy’s understanding of how Flovent works and then explain how Flovent reduces the chance of an attack.  He must also counsel Lucy by explaining that asthma attacks are still possible with Flovent and stress the fact that Flovent must be taken everyday. In this episode Lucy is fully compliant and intends to take her medication everyday even if she feels good.

 

          Episode two is set up for Lucy to be partially compliant. It deals with Lucy and her peak flow monitoring.  The pharmacist must first explore Lucy’s issues with her peak flow meter. Then, he must explain the need for daily monitoring. Also, with empathy the pharmacist must create a discrepancy involving Lucy’s desire to reduce flare-ups and not being able to predict when they will happen.

 

          The final episode focuses on issues between the pet bird and Lucy’s asthma. Lucy is strongly resistant to believing the bird can cause her to have asthma problems because she does not want her disease to cause problems for her brother.  The counselor should avoid argumentation, roll with resistance, and create discrepancy between Lucy’s desire to control her asthma and the negative effects feather dust can have on her health.  Additionally, the counselor should show empathy while maintaining firm in their concern over the bird and Lucy’s health.  The patient in this episode remains non-compliant.

 

          In conclusion, asthma counseling is a very important issue for pharmacists. In the United States alone, asthma leads to 5,000 deaths, 2 million emergency room visits, and 500,000 hospitalizations each year.  These numbers are expected to increase in future years due to changes in environmental conditions. In other words, every health care provider will be exposed to the treatment and counseling of asthma in one way or another. By understanding the basic causes of asthma, the general treatment plan, and the forms of patient non-compliance, health care providers, especially pharmacists, can assist patients in the most effective treatment of asthma. This will allow patients to live active normal lifestyles and will help to further develop the patient- pharmacist relationship.

         

 


Works Cited

 

“Asthma.”  UAB Health System.  2004.  University of Alabama at Birmingham. 

          13 November 2004.  <http://www.health.uab.edu/show.asp?durki=14820>

 

“NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of

Asthma.”  National Heart, Lung, and Blood Institute.  2003.  U.S. Department of Health and Human Services. 13 November 2004. <http://www.nhlbi.nih.gov/guidelines/asthma/asthmafullrpt.pdf>

 

“Overview of Expert Care for Asthma.”   ACAAI Home Page. 1996. The American            

          College of Allergy, Asthma and Immunology.  14 November 2004.

          <http://allergy.mcg.edu/physicians/green.html>

 

“Triggers.”   The Respiratory Institute.  1997.  GlaxoSmithKline.  14 November 2004.

          <http://www.respiratoryinstitute.com/the_basics_of_asthma/triggers.html>

 

“What are the Symptoms of Asthma?”  National Heart, Lung and Blood Institute.  2003.           U.S. Department of Health and Human Services.  13 November 2004.

<http://www/nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_

SignsAndSymptoms.html>

 

“What is Asthma?”  The Respiratory Institute.  1997.  GlaxoSmithKline.  14 November

          2004. 

<http://www.respiratoryinstitute.com/the_basics_of_asthma/what_is_asthma>

 


Appendix A:  Script Layout Diagram


 

 

 

 

 



Appendix B:  Script

[S1]

Patient = ""

Choice1 = "Hi Lucy.  How are you doing with your asthma medications?"

Action1 = S11

Choice2 = "Hello Lucy.  How's your asthma?"

Action2 = S11

Choice3 = "I'm glad to see you Lucy.  How is your asthma?"

Action3 = S11

Choice4 = "Hi Lucy. Are you taking your medication like I told you last month?"

Action4 = S111

Choice5 = "Lucy, I know you're taking that asthma medicine aren't you?"

Action5 = S111

Text1   = "Case I - Lucy is a 16 year-old female who was diagnosed with asthma three years ago. She was prescribed Flovent as a daily preventative and Albuterol for times of flare-up."

Text2   = "She was also given a peak flow meter and asked to keep a daily diary especially since her brother owns a bird and the doctor thinks the bird could be one of her asthma triggers."

Audio   =

 

[S11]

Patient = "Hey.  That Flovent didn't work."

Choice1 = "It’s frustrating when your medicine doesn’t work.  What happened?"

Action1 = S12

Choice2 = "I understand how frustrating that can be.  What happened with the Flovent?"

Action2 = S12

Choice3 = "Did you take it every day as prescribed?"

Action3 = S112

Choice4 = "Why?  Didn't you take your Flovent every day?"

Action4 = S112

Audio   = S11.wav

 

[S12]

Patient = "I took it for four weeks and then I had an asthma attack after jogging in PE.  I thought taking an inhaler every day would stop my attacks"

Choice1 = "Flovent is preventative in that it lowers your risk for an attack. Do you have time for me to tell you how it works?"

Action1 = S13

Choice2 = "How about I take some time to talk to you about how Flovent works as a preventative?"

Action2 = S13

Choice3 = "I apologize for not explaining how Flovent is a preventative that lowers your risk of attacks.  Do you have time for me to explain more?"

Action3 = S13

Audio   = S12.wav

 

[S13]

Patient = "Sure.  What does preventative mean?"

Choice1 = "Preventative means that the medication works so that you have fewer and less severe asthma attacks but it doesn't mean that you won't have them at all."

Action1 = S40

Choice2 = "Flovent is a preventative that should reduce the frequency and severity of your attacks, not stop them completely."

Action2 = S40

Audio   = S13.wav

 

[S40]

Patient = "Ok.  Why did I have an attack?"

Choice1 = "Asthma attacks are caused by triggers.  Tell me what your doctor told you about them."

Action1 = S14

Choice2 = "Your triggers can cause an asthma attack.  What do you know about them?  "

Action2 = S14

Audio   = S40.wav

 

[S14]

Patient = "My doctor said they are outside things that cause my asthma like smoke, exercise and pollen."

Choice1 = "That’s correct.  Even while taking Flovent, one of your triggers can cause you to have an attack."

Action1 = S15

Choice2 = "you're right.  Flovent will reduce the severity of a triggered attack."

Action2 = S15

Audio   = S14.wav

 

[S15]

Patient = "Oh.  So should I take Flovent every day?"

Choice1 = "Yes.  You should use it on days you feel great and on days you feel lousy."

Action1 = S16

Choice2 = "You're right.  Use it every day no matter how you feel."

Action2 = S16

Choice3 = "That's it.  It only works correctly when you use it every day."

Action3 = S16

Audio   = S15.wav


 

[S16]

Patient = "Am I going to have to take it the rest of my life?"

Choice1 = "I know the thought of taking daily medicine for the rest of your life is depressing.  What did you say your goal was for your asthma?"

Action1 = S41

Choice2 = "The thought of daily medicine for a chronic illness can be daunting.  What is your goal for managing your asthma?"

Action2 = S41

Audio   = S16.wav

 

[S41]

Patient = "I just want to be a normal teenager and not have to worry about my asthma."

Choice1 = "Daily Flovent with Albuterol when you have an attack will allow you to manage your asthma and have a normal life.  Just take it one day at a time."

Action1 = S17

Choice2 = "You can reach your goal by taking Flovent daily and keeping Albuterol handy for emergencies."

Action2 = S17

Audio   = S41.wav

 

[S17]

Patient = "I don’t guess it’ll be too bad."

Choice1 = "I'm glad to hear that.  Now let's talk about your peak flow diary."

Action1 = S20

Choice2 = "Great.  I know you can do it.  Now let's talk about the peak-flow meter?"

Action2 = S20

Audio   = S17.wav

 

[S20]

Patient = "That isn't going so well."

Choice1 = "I hate to hear that.  What do you find difficult about the diary? "

Action1 = S21

Choice2 = "Okay, let's talk about the problems that you are having."

Action2 = S21

Choice3 = "Well, it’s very important for you to gather this information."

Action3 = S121

Choice4 = "That's not good.  The diary is really important."

Action4 = S121

Audio   = S20.wav

 


[S21]

Patient = "I remember to do it on days my chest feels tight but I forget when I feel good."

Choice1 = "I know it is hard to remember.  Why do you think keeping a diary is a good thing?"

Action1 = S22

Choice2 = "I understand how difficult remembering can be.  Why do you think the diary is important?"

Action2 = S22

Audio   = S21.wav

 

[S22]

Patient = "My doctor said it would help me manage my asthma so I would learn my triggers and could tell when I might have an attack."

Choice1 = "That’s right.  Your peak flow values can drop before you feel bad and let you know to start the Albuterol."

Action1 = S23

Choice2 = "Yes, your peak flow values will drop before an attack so you can start using Albuterol to reduce its effects."

Action2 = S23

Audio   = S22.wav

 

[S23]

Patient = "So my peak flow value can be low even when I feel good?"

Choice1 = "Yes it can.  You can see the values drop 2 to 3 days before an attack."

Action1 = S24

Choice2 = "Yes, they will start to drop when an attack is imminent.  Such as when a weather front is coming through."

Action2 = S24

Audio   = S23.wav

 

[S24]

Patient = "I didn’t know that, but I still have trouble remembering."

Choice1 = "I know remembering can be hard.  Can I tell you how other patients remember to keep up with their diaries?"

Action1 = S25

Choice2 = "Would you be willing to hear how other patients remember to test the peak flow numbers daily?"

Action2 = S25

Choice3 = "If you're willing, I can help you schedule when to use your meter each day.  What do you do in the mornings?"

Action3 = S25

Choice4 = "You have to remember to do this."

Action4 = S124

Choice5 = "You will have to try harder."

Action5 = S124

Audio   = S24.wav

 

[S25]

Patient = "I'm open to suggestions."

Choice1 = "Other patients tie testing their peak flow with a meal eaten at a regular time each day and they get a relative or friend to help them remember."

Action1 = S26

Choice2 = "Some patients schedule their peak flow test with another routine, daily activity like eating and they ask a family member to help them to remember."

Action2 = S26

Audio   = S25.wav

 

[S26]

Patient = "Mom fixes me breakfast each morning.  I'll bet she would help me if I asked her."

Choice1 = "That's a great idea.  Now, let's talk about feather dust and asthma."

Action1 = S30

Choice2 = "I know you can do this.  Let's talk some more about birds and asthma."

Action2 = S30

Audio   = S26.wav

 

[S30]

Patient = "Yeah.  But I know my brother’s bird isn’t causing me problems."

Choice1 = "Ignoring your brother's bird for the moment, tell me about birds and asthma."

Action1 = S31

Choice2 = "Let's not be specific about your brother's bird.  What do you know about other birds and the asthma of other patients?"

Action2 = S31

Choice3 = "All birds produce feather dust which irritates air passages in the lungs.  I’m sorry but your brother’s bird is not good for you. "

Action3 = S131

Choice4 = "I think the brochure said that all birds produce a dust that can trigger asthma attacks.  That includes your brother's bird."

Action4 = S131

Audio   = S30.wav

 

[S31]

Patient = "Birds can give off some stuff, feather dust, that might trigger asthma attacks.  But my brother keeps his bird really clean."

Choice1 = "What would you do if you started wheezing while in the same room with your brother's bird?"

Action1 = S32

Choice2 = "You're correct about feather dust being an asthma trigger.  How would you handle it if you were around a bird and started having an attack?"

Action2 = S32

Audio   = S31.wav

 


[S32]

Patient = "I guess I'd use my inhaler and leave the room but that hasn't ever happened."

Choice1 = "What would you have to know in order to consider your brother’s bird is a trigger for your asthma?"

Action1 = S33

Choice2 = "Ok.  If I handed you an envelope, what would have to be written on the paper inside that envelope for you recognize that your brother's bird could cause an asthma attack?"

Action2 = S33

Choice3 = "You've been lucky so far.  I'm sure that the bird is one of your asthma triggers."

Action3 = S132

Choice4 = "Maybe you haven't paid enough attention.  I know that the bird's feather dust is harmful for you."

Action4 = S132

Audio   = S32.wav

 

[S33]

Patient = "I guess I would need to know that cockatiels produce this feather dust and that feather dust bothers all people with asthma.  But I still wouldn’t make my brother get rid of his bird."

Choice1 = "I know this is difficult but I'm still concerned about the feather dust."

Action1 = S34

Choice2 = "It is difficult to think about relocating a pet but I am more concerned about your health."

Action2 = S34

Audio   = S33.wav

 

[S34]

Patient = "Well, I've never had a problem with the bird."

Choice1 = "I hope that you will continue paying attention to your asthma triggers and when you are ready we can discuss some options for limiting your exposure to the bird."

Action1 = S35

Choice2 = "Again, for your safety please pay attention to your asthma around the bird and try to avoid spending time around it."

Action2 = S35

Audio   = S34.wav

 

[S35]

Patient = "Thanks for caring about me."

Choice1 = "You're doing really well with your medications and I know you can handle the peak flow.  We'll discuss other issues when you return in a month."

Action1 = S999

Choice2 = "Well, I'm really proud of how you've done with your medication so far and I know you'll continue to improve.  We'll discuss this again next month."

Action2 = S999

Audio   = S35.wav

 


[S111]

Patient = "I stopped when I had an asthma attack ‘cause it wasn’t working."

Choice1 = "Flovent will reduce the frequency of your attacks but only if you take it every day."

Action1 = S112

Choice2 = "You have to take it every day to reduce the frequency of your attacks."

Action2 = S112

Choice3 = "The medication does not work properly unless you take it every day."

Action3 = S112

Audio   = S111.wav

 

[S112]

Patient = "I did take it every day.  Why did I still have an attack?"

Choice1 = "Didn’t your doctor explain about triggers for asthma?  Even with Flovent, a trigger can cause an attack."

Action1 = S113

Choice2 = "I thought your doctor and I explained how Flovent is preventative and you can still have an attack."

Action2 = S113

Audio   = S112.wav

 

[S113]

Patient = "Will I have to take it for the rest of my life?"

Choice1 = "Yes, if you want to manage your asthma and stay out of the ER."

Action1 = S114

Choice2 = "Yes.  Otherwise you'll never get your asthma under control."

Action2 = S114

Choice3 = "I know the thought of taking daily medicine for the rest of your life is depressing.  What did you say your goal was for your asthma?"

Action3 = S41

Choice4 = "I understand it is difficult to manage a chronic disease with daily medication.  What is your goal for managing your asthma?"

Action4 = S41

Audio   = S113.wav

 

[S114]

Patient = "If you say so."

Choice1 = "I do say so.  How is it going keeping a peak-flow diary?"

Action1 = S20

Choice2 = "I know you'll see I'm right in time.  How are you doing with the peak-flow meter?"

Action2 = S20

Audio   = S114.wav

 


[S121]

Patient = "It’s hard to remember ‘cause I’m really busy."

Choice1 = "You won’t be able to manage your asthma well without it."

Action1 = S122

Choice2 = "Surely managing your asthma is important enough to remember?"

Action2 = S122

Audio   = S121.wav

 

[S122]

Patient = "I feel good most of the time.  I don’t see why it’s so important."

Choice1 = "Feeling good is not an objective indication that your asthma is under control."

Action1 = S123

Choice2 = "You need objective readings of your lung performance to keep your asthma under control."

Action2 = S123

Audio   = S122.wav

 

[S123]

Patient = "So."

Choice1 = "You need real numbers from the meter to predict when you’ll have another attack."

Action1 = S124

Choice2 = "You really can't figure out your triggers without a peak flow diary."

Action2 = S124

Audio   = S123.wav

 

[S124]

Patient = "I just can’t remember with all my schoolwork and extracurricular activities."

Choice1 = "I’m sure your mom could help you to remember.  It’s very important."

Action1 = S125

Choice2 = "I know your mom is willing to help.  You need to ask her."

Action2 = S125

Choice3 = "I know this is hard and would like to help.  Can I tell you how other patients remember to keep their diaries?"

Action3 = S25

Choice4 = "I understand how difficult and frustrating this can be.  Can I tell you methods other patients use to help them remember?"

Action4 = S25

Audio   = S124.wav

 

[S125]

Patient = "I can take care of myself.  I’ll do it."

Choice1 = "Well, you need to do it.  Let's continue talking about birds and asthma triggers."

Action1 = S30

Choice2 = "It's very important.  Now, we need to talk about feather dust and asthma."

Action2 = S30

Audio   = S125.wav

 

[S131]

Patient = "But I never cough around the bird and she stays really clean."

Choice1 = "Clean or dirty, all birds produce the irritating dust and is contributing to your asthma."

Action1 = S132

Choice2 = "Cleanliness doesn't not have anything to do with the feather dust."

Action2 = S132

Choice3 = "Do you think it’s possible that a bird’s feather dust could trigger an asthma attack?"

Action3 = S132

Audio   = S131.wav

 

[S132]

Patient = "Well, it’s not a big problem for me and my brother would never forgive me."

Choice1 = "Bring your brother here to talk to me and I’ll show him test results from birds and asthma sufferers."

Action1 = S133

Choice2 = "I'd be happy to provide you and your family the results of tests showing that feather dust triggers asthma attacks."

Action2 = S133

Choice3 = "I understand how difficult this can be, but I'm still concerned about your exposure to feather dust."

Action3 = S34

Choice4 = "I know this is a hard choice and I want you to know that I am concerned about your health."

Action4 = S34

Audio   = S132.wav

 

[S133]

Patient = "I am not interested in your test results and neither is my brother."

Choice1 = "Well, they’re your lungs.  I'll see you next month."

Action1 = S999

Choice2 = "You're only hurting yourself.  I'll see you next month."

Action2 = S999

Audio   = S133.wav


PYPC 5040   Fall Semester 2004

Virtual Patient Grading Form

 

Group Number:  1                        Disease State:   Asthma

 

Group Members: 

 

Background Information about Disease State:  (30 points subtotal)

Basic description of the disease state                           (8 points)                8

          Treatment goals                                                       (8 points)           8

Major sources of noncompliance                        (8 points)           8

Consequences of noncompliance                        (6 points)           6

         

Patient Profile:  (15 points subtotal)

          Details of patient’s medical and social history                 (6 points)          6

          Details of patient’s noncompliance                      (9 points)          9

 

Rationale and Strategy for 3 episodes:   (15 points subtotal)

          Episode 1                                                       (5 points)           5

                   Counseling strategy for BM:

                   Counseling strategy for MI:

                   Nature of outcome:

          Episode 2                                                       (5 points)           5

                   Counseling strategy for BM:

                   Counseling strategy for MI:

                   Nature of outcome:

          Episode 3                                                       (5 points)           5

                   Counseling strategy for BM:

                   Counseling strategy for MI:

                   Nature of outcome:

 

Script:   (30 points subtotal)

          Realistic portrayal of patient’s perspective          (3 points)           3

          Portrayal of traditional BM approach                            (3 points)           3

          Portrayal of MI approach                                  (6 points)           6

          Range of MI processes and skills                          (10 points)           8     see next page

Quality of choice points in the script                            (4 points)           4

          Varied phrasing in alternative responses                       (4 points)           4

 

Quality of Scripted Interaction:   (10 points subtotal)

          Emotional tone of the patient & pharmacist                  (3 points)           3

          Smooth integration of all paths                                   (3 points)           3

          Dynamic realistic interaction                                       (4 points)           4

 

 

                                                                                   Total out of 100  =    98

 

 

 

 

          Comments for Group 1

 

Very nicely done!  

 

Your report was detailed, solid and insightful.  I liked your choice of episodes and forms of noncompliance.

 

       Good use of the envelope technique in the bird episode.  I would recommend that you explore more the decisional balance involving the bird.   Get Lucy to consider the pros and cons from her perspective.  You might even consider asking what her brother would feel the pros and cons were for keeping his bird if he knew that feather dust can cause serious problems for people with asthma.  She might realize that he could be more concerned about her than about his bird – assuming she has a nice brother who wants the best for her. 

 

You can be very proud of your work.

 

 


Evaluation

 

Qualitative analysis of comments on feedback indicates that there are two interrelated reactions that were common across the whole class.  First, there were too many problems with the computer portion of the assignment.  Second, the project took too much time when many students wanted to be studying for final exams.  Many students commented that they spent too much time on getting the script to work with the AUVP.  Clearly, the computer programs need to be stabilized and finalize if the entire project is to be repeated next year.  Probably a better alternative would be to introduce the students to the AUVP and then have them write a script that would not have to actually work.  This approach would make the students into content matter experts and script writers with no necessity of handling any computer procedures other than a word processing program.

 

Other reactions clearly broke the class into three groups.  One group was stimulated by the assignment and felt that writing the script had helped them to a clearer understanding of how to use MI principles in counseling a patient.  Some students noted that the script writing required critical thinking that they appreciated.  However, they also noted that the computer complexities detracted from keeping the focus on the script.  These students appear to have a very positive image of MI and gave indications that they expected to utilize MI in the future. 

 

The second group, which formed the majority of the class, had mixed feelings about the assignment.  They did note the helpfulness of having to write the report and the script.  However, they felt overwhelmed by getting the computer programs to operate correctly.  The computer experts from these groups often indicated that their computer background was minimal and they did not feel that learning these programs was going to benefit them as pharmacists.  A few people remarked that the paper and the script were sufficient to achieve the goals of the assignment.  Finally, many of these groups exhibited signs of unequal distribution of the workload.  Students remarked that they had handled much more work than other members of their group.  In one group, two members were “social loafers” and did not work on the project.  The other two members seemed to feel that that the assignment was at fault for allowing this to happen.  We do feel that some accountability for individual contribution to the group needs to be built into the assignment next year. 

 

The final group was comprised of students with very negative attitudes about the assignment.  They resented the amount of time it required, especially because they saw no value in learning to use MI.  They perceived MI to be an esoteric useless topic that they would never use.  In more positive terms, they saw no learning benefits from the assignment. In more negative terms, one student commented that you cannot teach talking to student pharmacists; they either get it or they don’t.  Therefore, don’t waste our time.  Another student contended that the paper was enough; there was no need to write the script.  The feeling of this group was that they had lots of facts to learn for their final exams.  Underlying this attitude seems to be 1) the conviction that we already know how to talk, and 2) the belief that education is a matter of memorizing what they are given to learn.  It is possible that eliminating the computer element may allow some of these students to be stimulated by the assignment.  However, the underlying attitudes make this unlikely.

 

A quantitative analysis was performed of the 100 multiple choice questions on the final exam.  The questions were divided into three groups.  The first group tested MI with a dialogue format.  The second author wrote a special 10 question section in which the students were to choose the MOST appropriate response MI response to a patient’s utterance.  The questions were sequenced to form an ongoing dialogue with the same patient.  A sample question follows:

 

Patient:  I know I need it, I don’t like the idea of having to take a drug every day.

Pharmacist:  

a.  At least you can afford to take medicine every day.

b.  You don’t understand why this is necessary.

c.  You don’t like having to depend on taking medicine.   (correct answer)

d.  It’s really your choice.

 

Along with four other dialogue based MI questions elsewhere in the exam, there were a total of 14 such questions.  Each student’s total score on these questions was converted to a percentage. The second group of questions were typical multiple choice questions testing the theoretical concepts undergirding MI.  There were a total 37 such questions. The final group was composed of multiple choice questions testing other topics in the course.  The descriptive statistics were as follows:  

 

Dialogue Based MI questions:     X = .886,  SD = .088

                   Theory Based MI questions:        X = .870,  SD = .083

                   Other Questions:                          X = .760,  SD =  .076

 

Given that two of these distribution of scores were not normally distributed, tests of these paired means were conducted using Proc Univariate in SAS 9.1.  All three two tailed Wilcoxen Signed Rank tests were significant.  The students scored approximately one percentage point better on the Dialogue Based MI questions than on the Theory Based MI questions (p<.022).  Scores on both types of MI questions were significantly better than scores on the Other questions (p < .0001).  This difference amounted to slightly more than a full letter grade (.11). 

 

          The results of the item analysis were surprising.  The author of the Dialogue Based questions expected the students to have difficulty with them.  Instead, they answered them significantly better than any other questions on the exam.  More surprising is their better performance across all MI questions, regardless of type, than on the other questions on the exam.  We suspect that the active learning involved in the script writing assignment spread across both the dialogic and theoretical domains of MI.  We are currently in the process of trying to analyze scores on items that were common to this year’s final and last year’s final to determine whether the Theory Based MI questions were answered better this year than last year.

 

Practicality/Workability/Transferability

 

In its current prototype version, the AUVP is still somewhat buggy because it was intended as a “proof of concept”.  The reliability of the speech recognition engine can vary from machine to machine because of how Visual Basic calls various routines involved in speech recognition.  We have already determined that programming the AUVP in a browser environment offers no advantages and introduces some new problems such as unavoidable flashes as each video clip starts playing.  Currently we are experimenting with using a higher order authoring system such as Authorware that should minimize machine to machine variation, allow for tracking student performance over the web, and simplify the installation process.  We expect that the first public version of AUVP should be ready for testing within six months.  We hope to use experienced actors and high quality video to produce a CD with 8-12 virtual patients for use by any interested school of pharmacy.  We expect the AUVP to be easily used by any student with a recent laptop computer equipped with a good microphone, processor and display. 

 

The assignment of writing a script for a Virtual Patient is also easily used in other contexts, especially if the assignment is divorced from the requirement of having the script actually work with the AUVP engine.  In other words, students could be shown the AUVP, and then asked to write a script much as a Content Matter Expert might do.  The format for the script could be simplified down to its most basic form.  In this manner, all the computer problems encountered in our project would be avoided.   The students would derive the educational benefit of struggling with how to word their MI responses.  Professors considering this assignment should be aware that much of the pedagogical benefit is derived from the periods of consultation with individuals, small groups and large groups.  The time investment required of the professor is considerable.  With a class of 125 students, the second author spent about 20-30 hours consulting over the span of the assignment.  In our view though, this was time well spent in providing a high quality educational experience.

 

Personal Reflections

 

The AUVP has excellent potential to provide students with their first opportunity to use MI in counseling rather realistic virtual patients with various medical conditions.  It would appear to be the appropriate next step after completing lectures and readings about the nature and techniques of MI.  Unsolicited remarks by other students who have seen the AUVP in operation indicate that they find the virtual patient realistic and engaging.  They react to comments by the virtual patient in a fairly spontaneous fashion, as can be seen in the previously mentioned video file (AUVP_video.wmv) where the student chuckles at the patient’s comment about the low fat diet being about as appealing as eating tree bark.   They say that the AUVP has the feel of normal conversation.  Secondly, students seem to appreciate the opportunity to explore how their comments can affect the progression of the counseling session.  They like the idea of experimenting with how patients react to the MI and BM models of counseling.  Finally, students seem to like the idea that they can find ways of wording and implementing MI with which they identify.  In other words, they are able to find their own MI “voice”.  We expect that the AUVP will become a valuable pedagogical tool in teaching MI to first year students.  The natural follow-up to the AUVP would be to role play with each other in order to make the transition to using MI in their own words in real time.  The last step would be to practice with a standardized patient. We believe that students trained in this fashion should have an elementary mastery of MI.  Such students should be more inclined to improve their counseling as they progress into professional life.  Ultimately they should be more able to handle medication management therapy services than pharmacists rooted solely in the biomedical model of patient counseling

 

We have identified the need for a coaching function in the AUVP.  Essentially this would involve freezing the video window of the patient and opening up a second video window with a MI expert (such as the second author) analyzing the interactional situation and discussing various options for how to proceed.  Such a coaching function could be enhanced by background programming to identify patterns in the choices made by the student thus far in the interaction.  Ideally, in a series of virtual patients, the coaching function would be maximized in the first few patients, and decreased in subsequent patients until it is an option in the final patients.

 

We have found the script writing assignment to be a very challenging and active exercise in assimilating the verbal skills necessary for using MI in patient counseling.  While some students exhibited greater interest in MI, greater knowledge of why MI is successful, greater facility with wording MI responses, and greater confidence in their ability to use MI in the future, other students had negative reactions to the computer portion of the project and the time involved.  Although the second author expected the students to have a difficult time with the dialogue based final exam questions, they did significantly better on all of the MI questions (both dialogue based and theory based) than on the questions testing other areas of content in the course.  This significant difference was the equivalent of a full letter grade!  Apparently the students learned more about MI than they may have been aware of.

 

The most major deficiency in the script writing assignment occurred in those groups of three to four students that subdivided the assignment into separate tasks handled strictly by individuals.  This approach guaranteed that one to three students were never involved in writing the script.  The worst situation was that faced by the “computer expert” who handled all the data entry and computer techniques without helping to author either the report or the script.  We plan to correct this deficiency next year by assigning the project to pairs of students.  In addition, the AUVP engine and the authoring program should be relatively stabilized by next fall so that the computer procedures will be fairly straightforward and the grading can be handled by GTAs. 

 

We are extremely optimistic about the educational opportunities afforded by the AUVP itself.  As we have shown the program to colleagues from other departments, we have been struck by the creative applications they see for it in the P2, P3 and P4 years.  Some of their suggestions include the following:

 

1.   Use the AUVP to introduce new P1 students to what they might expect in visiting their newly assigned patient in the Pharmacy Practicum Experience.  This visit, which happens usually in the second or third week of their first semester, is a source of anxiety for many students because they do not know what to expect from their patient and what they might say as student pharmacists.

 

2.   Use the AUVP to have students practice history taking in their Physical Assessment course.

 

3.   Use the AUVP as the final step in case studies during the problem based modules that comprise the final three semesters on campus at AU’s Harrison School of Pharmacy.  After diagnosing a patient’s condition and recommending several possible medication regimens, the students would then monitor and counsel the patient in one or more sessions as their prescriptions are refilled.  This use would more thoroughly integrate counseling into problem based learning.

 

4.   Use the AUVP to practice techniques of communicating with patients having communication disabilities such as varying degrees of hearing loss, or having cognitive impairments such as Alzheimer’s.

 

5.   Use the AUVP as a refresher for P4 students about to start their P4 rotations in various clinical and community settings.

 

6.  Use the AUVP to give P4 students on rotations exposure to types of patients or medical conditions that may not be available to them in the region to which they have been assigned. 

 

The AUVP can handle any of these uses as long as the interaction can be based on the provision of a restricted set of possible responses from which the user chooses.  Because the runtime engine is separate from the authoring system, any professor or researcher interested in creating a virtual patient can do so with simple video production techniques.  We envision creating a shared library of virtual patients by requiring anyone using the authoring system to contribute their virtual patient to this library.   

 

It should be noted that the AUVP engine is essentially content free and can be used to simulate any type of verbal interaction.   For example, the roles could be reversed so that it is a Virtual HCP for training patients how to communicate with their HCPs.  Or it could be used outside the healthcare field as a Virtual Customer or a Virtual Salesperson. 

 

Our plans for the second version of the AUVP is to free up the constraints placed on the range of responses open to the student.  Essentially this step would require a fairly powerful system of natural language processing that would allow the student to use their own words and phrasing.  There are two ways that this goal might be achieved.  First, a semantically driven natural language processor may be made publicly available for research and pedagogical purposes.  Often such programming is an abridged version of a more powerful commercial product.  Second, instead of relying upon one generalized natural language processor for parsing all student comments, very simple individual grammars might be generated for each state in the interaction.  Such grammars could rely more on the processing of keywords (as used previously by Eliza) than by analyzing the underlying meaning of a student’s utterance.  Such an approach would be feasible but time consuming. However, we are certain that virtual humans will revolutionize interaction skills training in the next decade.  We hope that the AUVP will help to pave the way within the field of health care education.

 

 

 


References

 

1.   Bearman, M.  (2003).  Is virtual the same as real?  Medical students’ experiences of a virtual patient.  Academic Medicine, 78(5), 538-545.

2.   Bergin, R.A. & Fors, U.G.H. (2003).  Interactive simulated patient – an advanced tool for student-activated learning in medicine and healthcare.  Computers and Education, 40, 361-376.

3.  Berger, B.A., Hudmon, K.S., & Liang, H. (2004). Predicting treatment discontinuation among patients with multiple sclerosis: application of the transtheoretical model of change. J Am Pharm Assoc, 44(4): 445-454 (July-August).

4.   Berger, BA, Liang, H, Hudmon, KS. Development and evaluation of software based on the transtheoretical model of change and motivational interviewing to enhance medication persistency with AvonexR.  J Am Pharm Assoc. in press, 2005.

5.   Bryce, D.A., King, N.J.C., Graebner, C.F., & Myers, J.H. (1998).  Evaluation of a diagnostic reasoning program (DxR): Exploring student perceptions and addressing faculty concerns.  Journal of Interactive Media in Education, 98 (1).  (http://www-jime.open.ac.uk/98/1; accessed on 1/10/2005.).

6.   Buber, M. (1970).  I and Thou.  NY, NY: Touchstone Books.

7.    DiClemente CC, Prochaska JO. Self‑change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance. Addict Behav. 1982(7):133‑142.

8.     Hubal, R.C., Frank, G.A. & Guinn, C.I.  (2003).  Lessons learned in modeling schizophrenic and depressed responsive virtual humans for training.  Paper presented at the 2003 International Conference on Intelligent User Interfaces, Miami, FL.

9.     Hubal, R.C., Kizakevich, P.N., Guinn, C.I., Merino, K.D., & West, S.L.  (N.D.)  The Virtual Standardized Patient: Simulated patient-practitioner dialog for patient interview training.  (http://www.rvht.info/pubs/mmvr.01.28.00.pdf;  accessed on 1/10/2005).

10.    Link, M.W., Armsby, P.P., Hubal, R., & Guinn, C.I.  (2002).  A test of responsive virtual human technology as an interviewer skills training tool.  Paper presented at the 2002 Annual Conference of the American Association for Public Opinion Research, St. Petersberg, FL. 


11.   Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for  change (2nd ed.). NY, NY: Guilford Press.

12.   Norcross, J.C., Prochaska, J.O., & DiClemente, C.C. (1986).  Self‑change of psychological distress: laypersons' vs. psychologists' coping strategies. J Clin Psychol, 42, 834‑840.

13.  Prochaska, J.O., & DiClemente, C.C. (1984).  The transtheoretical approach: Crossing traditional boundaries of therapy. Homewood, IL: Dow Jones‑Irwin.

14.  Prochaska, J.O., & DiClemente, C.C. (1985).  Common processes of self-change in smoking, weight control and psychological distress. In: Shiffman, S., & Wills, T.A., (Eds.), Coping and substance abuse. New York, NY: Academic Press, 345-363.

15. Prochaska, J.O., Velicer, W.F., Guadagnoli, E., et al. (1991).  Patterns of change: dynamic typology applied to smoking cessation. Multivar Behav Res, 26, 83‑107.

16. The Virtual Conversations for STD/HIV Risk Assessment program, http://idrama.com/HIVseries.htm; accessed on Jan 10, 2005)

17. Triola, M.M., Feldman, J.J., Kachur, E., Holloway, W.J., & Friedman, B.S. (2004).  A novel feedback system for virtual patient interactions.  In: Fieschi, M. et al. (Eds.), MEDINFO 2004. Amsterdam, IOS Press, 1886.

18. Warner, C. T.  (2001). Bonds that make us free:  Healing our relationships, Coming to ourselves.  Salt Lake City, Utah: Shadow Mountain. 

19.  Willey, C., Redding, C., Stafford, J., Garfield, F., Geletko, S., Flanigan, T., et al. (2000). Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure. Clinical Therapeutics, 22(7), 858-871.

 

 

 


 

 

 

 

 

 

 

 

 

January 11, 2005

 

 

Ms. Jennifer M. Patton

Innovations in Teaching Competition

American Association of Colleges of Pharmacy

1426 Prince Street

Alexandria, Virginia  22314-2841

 

Dear Ms. Patton,

 

Please accept these five copies of our portfolio for consideration in the Innovations in

Teaching Competition.  Note that there are five CDs to go along with the written documentation.  The length of the section on evidence of student learning is longer than specified because it includes a copy of one student project as turned in.

 

Insofar as I am the senior author, please address all correspondence to me. 

 

My coauthor Bruce Berger is already a member of AACP.   Would you please be so kind as to send me a membership application?

 

Sincerely,

 

 

William A. Villaume, Ph.D.