Sophia Yapalater watched intently as the attending physician swept into the room and began examining the disoriented, lethargic patient. Though the fourth-year medical student acted like a fly on the wall, she listened closely as the doctor noted the patient’s irregular heartbeat, wheezing chest, and swollen ankles. Was it sepsis? As the nurse read off the patient’s concerning vital signs, Yapalater considered next steps the doctor might take, like putting him on oxygen and starting antibiotics. “What would you like to do?” the nurse asked.

But the question wasn’t posed to the attending: It was up to Yapalater to decide.

This scenario was part of the annual Transition to Internal Medicine Internship course — also known as Internal Medicine Boot Camp — at the Perelman School of Medicine (PSOM) at the University of Pennsylvania. Designed for future Internal Medicine residents, the course provides graduating students with valuable opportunities to sharpen their time management, communication, interpretation, application, and decision-making skills before they enter their intern year. After a week of skills refreshers guided by faculty and standardized patients, students put their expertise to the test with a series of intensive scenarios during a simulated “Day in the Life of an Intern” capstone experience.

Though the objectives have remained consistent over the last decade, the course has evolved since its inception, most recently in response to the COVID-19 pandemic. To promote social distancing, Boot Camp 2021 was entirely virtual, combining Zoom meetings with virtual reality (VR) technology.

A New Format for a New Era of Medical Education

Stacey Kassutto, MD, took the first version of Boot Camp when she was a medical student in 2010. Later, when she became a Pulmonary Critical Care Fellow, she helped to transform it from a two-day course focused on bedside procedures like placing IVs to a weeklong course that effectively prepares students for the busyness of their intern year through lifelike simulations.

Pre-pandemic, students would attend lectures on topics like reading EKGs and calling consults, as well as workshops focused on communication challenges such as breaking bad news and navigating low health literacy. Students then visited the Penn Medicine Clinical Simulation Center for their “day in the life” experience, working through scenarios like resuscitating a mannequin and holding a goals-of-care conversation with a standardized patient. Amidst all of this, students received calls and pages from nurses and consultants (played by Kassutto) posing questions like, “Your patient is nauseous; what would you like to do?”

Physicians and standardized patients filmed video scenarios for medical students to watch and respond to during their Internal Medicine Boot Camp course. (Photo credit: Kyle Cassidy, Annenberg School)

Though the pandemic threw several wrenches into her plans, Kassutto, now the course director for Boot Camp and director of Simulation for the Internal Medicine Residency, was undaunted; she began developing online content for 2021 as soon as the 2020 course ended. It helped that she was already working on a project focused on introducing VR and other novel technologies into the PSOM curriculum alongside Suzana Tsao, DO, vice chair of Education in Emergency Medicine, and Caitlin Clancy, MD, director of Curricular Analytics, Innovation, and Technology for Undergraduate Medical Education. Inspired by COVID’s dramatic impact on medical education, the Measey Learning in a Virtual Environment (LiVE) longitudinal project — which is funded by a grant from the Benjamin and Mary Siddons Measey Foundation — aims to complement the current pre-clinical and clinical curricula with virtual learning opportunities throughout students’ training.

“As we considered the different aspects of the grant and the areas where we could pilot things we wanted to try with more advanced students, Boot Camp was a natural fit,” Kassutto said. With the support of Tsao and Clancy, Kassutto allocated some of the Measey LiVE funding to enhance the course with computer-generated scenarios, pre-filmed scenarios, and other online content.

“The logistics of any new technology are a challenge,” she said, “but the pandemic has forced us to expand our horizons in the educational sphere, and exploring the possibilities of VR technology can really provide students with immersive and interactive opportunities.”

An Interactive and Immersive Experience

Since many students have become Zoom experts by now, the virtual transition was straightforward for much of the 2021 course; lectures on topics like informed consent and discharge planning were moved online, while workshops related to antibiotics and handoffs were shifted into virtual breakout rooms.

The discussions about palliative care were especially helpful for fourth-year medical student Michael Perez, who will intern in Internal Medicine for a year before continuing his training in Neurology at the Hospital of the University of Pennsylvania (HUP).

“It was particularly powerful when one of the lecturers remarked that these conversations should be treated like any other procedure in surgery,” he said. Though initiating dialogues about end-of-life can be challenging, it is a skill that physicians can refine over time. “It requires technical competency to execute meaningful and productive end-of-life conversations, and I appreciated learning about the skills and tools I can employ to best care for patients and their families.”

Pivoting the capstone experience required a bit more planning, but Kassutto and other faculty were able to create an impactful, immersive experience. For example, rather than gathering in-person to practice resuscitating a mannequin in cardiac arrest, students logged onto a multiplayer simulation platform. Each person had an avatar in the virtual room, and they could talk to each other and click to start compressions, access the crash cart, connect the patient to the defibrillator, and take other actions.

“It put me in the mindset of being in the role of physician — something that still hadn’t totally hit me as real!” said Yapalater, who will also stay at HUP for residency. “It was great to work with my classmates and practice team-based communication and clinical decision-making. We had to play on one another’s strengths, which is an important aspect of medicine.”

For a more fully immersive experience, students also participated in cases using VR headsets; wherever they turned their heads, they could see different parts of a computer-generated exam room. When asking questions like, “What brings you in today?” or “Where is your pain?” their virtual patient would reply in real-time using voice-recognition technology. Based on the history and physical exam findings, students could then click to order diagnostic tests like a metabolic panel or X-ray before making their diagnosis. Pre-filmed video simulations like the scenario with the human standardized patient in septic shock also required students to interpret charts, order tests, call codes, and make other choices each time the clips paused.

“A lot of the cases reminded me of actual clinical emergencies I had witnessed,” Perez said, “Seeing how comfortable I was with appropriately evaluating and managing these emergencies proved to me how effective and exceptional the clinical training is at PSOM. The experience was such an excellent final test of our four years of medical school.”

Virtual Training, Very Real Lessons

As Kassutto looks ahead to the future of Boot Camp, she’s eager to reinstate some of the in-person components of the course. VR technology hasn’t quite reached the point where a student could practice placing an IV or EKG from their bedroom; they simply can’t get the same tactile sensations they’d get working with a simulation mannequin. Nonetheless, the experience has illuminated many opportunities for growth and change within the curriculum.

“Next year, we’re hoping to expand the length to two weeks, partially because we recognize that not everything in the course needs to be done synchronously. Students like being able to learn on their own time, in their own way,” she said. And it isn’t just the students who benefit from the flexibility offered by VR simulations. “We typically need huge numbers of faculty to make this work in-person. Virtual reality can expand the learning and give students rich experiences without the same intensity of faculty support.”

By virtue of being virtual, the 2021 course also pushed students to test new platforms and adapt to new tech — an invaluable skill in the ever-evolving medical landscape. As Yapalater notes, even beyond the COVID-19 pandemic, technology is becoming an increasingly integral aspect of the field. “Being able to communicate effectively with patients over telehealth and video platforms is a specific skill set that, just like anything else, needs to be honed in medical training,” she said.

Kassutto agrees. “I know so much more now about how VR technology works than I did even six months ago. While certain parts of the curriculum are still better in person, it’s clear to me that others can be enhanced by having some of these additional technologies,” she said. “There’s a learning curve, but there’s also a lot of opportunity and a lot of possibility.”