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Involvement of medical experts in legal proceedings: an e-learning approach

Involvement of medical experts in legal proceedings: an e-learning approach E-learning programs based on the "Virtual Patient" paradigm familiarize students with the process of combining information derived from different branches of medical science. In addition, medical practice often requires paralegal knowledge ­ for example, when determining the degree of disability or taking part in medical malpractice proceedings. This paper serves as an introduction to inclusion of modern IT tools in teaching curricula. Such tools are available to almost every student of medical sciences and frequently employ the "Virtual Patient" concept mentioned above. For the purposes of our study, we have prepared a selection of training materials using the CASUS software. The specific features of our study include involvement in legal proceedings based on a retrospective approach, i.e., reconstruction of past events. Keywords: medicine. clinical pathology; E-learning; forensic and parcel of modern medical curricula. Deploying new technologies usually introduces tensions, and e-learning is no exception. Some wish to use it merely to perform preexisting activities more efficiently or faster, others pursue new ways of thinking and working that the use of such technology affords them. For healthcare, e-learning's goal is education, not technology, because the student must be aware that he/she cannot always predict the outcome of a medical case. Sometimes, the physician has to take risks, and "see what happens". Serendipity often adds to the excitement of teaching. It certainly adds to the excitement of learning. The use of technology in support of education is not, therefore, a causal or engineered set of practices; rather, it requires creativity and adaptability in response to the specific and changing contexts in which it is used [1]. In many countries, using e-learning platforms by students turned out to be beneficial. For example, at the University of Müenster, 15 virtual cases of death have been developed by using the web-based Inmedea Simulator, and the overall reception of the program by the medical students resulted to be positive [2]. In Scandinavia at the "Civil and Commercial Law" 4 ECTS course, its organizers adopted a medical VC system to teach law. In the course, the virtual case system Web-SP was used by the students, which originally was developed for healthcare education and offered possibilities to interview the client, perform physical examinations, order lab and imaging tests, plus suggest proper diagnosis and treatment, to teach general law, civil law, real estate law, and construction law. As a result, students wanted more virtual cases like these in the course in their future studies [3]. The experiment described by Kopp et al., a case-based, worked example approach was realized in a computer-based learning environment with the intention of facilitating medical students' diagnostic knowledge turned out to be effective and efficient [4]. Despite this increasing use, the empirical basis for an optimal integration strategy of computerized teaching methods is small for medical education. In addition to general aspects of integrating e-learning into a curriculum, like feasibility, software and content requirements, or curriculum structure, the integration strategy, with respect to motivational aspects and acceptance of DOI 10.1515/bams-2014-0009 Received May 26, 2014; accepted May 26, 2014; previously published online July 4, 2014 Introduction The content of medical learning curricula in Poland are broad, covering such disciplines as anatomy, physiology, biochemistry, histology, biology, pharmacology, pathology, pathophysiology, and many clinical specializations ­ internal diseases, surgery, gynecology, obstetrics, and pediatrics, to name just a few. The student is faced with a generalized or detailed (depending on the chosen specialization) view of the given field ­ such as dermatology, neurology, ophthalmology, otolaryngology, infectious diseases, endocrinology, etc. E-learning applications are part *Corresponding author: Irena Roterman-Konieczna, Department of Bioinformatics and Telemedicine, Medical College, Jagiellonian University, Lazarza 16, 31-530 Cracow, Poland, E-mail: myroterm@cyf-kr.edu.pl Dygut Jacek: Hospital in Przemyl, Przemyl, Poland Sylwia Plonka: Faculty of Physics, Astronomy and Applied Computer Science, Cracow, Poland 160Jacek et al.: E-learning in medicine both students and instructors, and exam-relevance of the content is crucial [5]. In Poland, medical practitioners are often expected to not only apply their professional judgment but also remain capable of justifying their decisions on legal grounds; therefore, the medical training based on the Virtual Patient platform has been extended with legal aspects related to the structure of the healthcare system and patient rights. In addition, the teaching materials were augmented with a section covering materials from court proceedings concerning medical malpractice in both diagnostics and therapy. Virtual patients (VPs) are computer simulations of real-life clinical scenarios created for the purpose of healthcare and medical training, education, or assessment. The case described in this article has been implemented in the CASUS system, which is a web-based VP shell developed by LMU University of Munich and implemented at Jagiellonian University in Poland. The CASUS system enables the authoring of VP cases, course management, as well as the tracing of students' activities [6]. CASUS is a case-based learning system, which is integrated into the medical curriculum of various medical schools [7]. At the University of Munich in Germany, the level of acceptance among participants toward learning with computers, doing computer-based examinations, and the usability of the system in the context of computerized National Boards examinations were examined. Some of the students had concerns about the required technical reliability and data safety of the examination system, but generally, the level of acceptance was high [8]. The platform used at Jagiellonian University in Poland required that medical students combine their professional knowledge in the area of orthopedics with legal experience in order to issue an opinion regarding medical malpractice: the case concerned a female patient with serious complications, which should not normally occur after such a long period of time (a crural fracture caused by falling on a slippery surface should no longer be detectable after 7 years). The student's task was to investigate the case, identify causative factors, and determine the medical malpractice point. Materials and methods Materials The students were presented with the e-learning environment case materials shown on screen cards. Each screen card was an exercise to solve, associated with the discussed complications after a crural fracture. Materials gathered to implement the case in the VP platform were taken from the medical records of the patient (in compliance with applicable personal data protection laws) and transformed into e-files. The materials presented to the student were accompanied with multimedia files: images, video files, as well as expert comments. The general goal of the described-here e-task was to identify the reasons behind the mistreatment of the fracture. The first screen card of the program (Figure 1) served as an "introductory" point of the case. It familiarized the Figure 1Sample screenshot introducing the student to the case in the CASUS system. Jacek et al.: E-learning in medicine161 student with information on the accident and was followed by additional pages with details on the patient's history, diagnostics, therapy, and physical examination. Comments of the medical expert were attached to each page. Seven years after the accident, the patient should have no vivid recollections of the event or the progression of the case. Methods The CASUS system tasks consisted of trial-and-error exercises. Among them, the most common were multiplechoice questions; free-text query; request to underline correct answers; mix-and-match query; free-text query not subject to grading; "lab data" query; "long menu" query; request to fill in gaps in description; request to establish causation. Students could read the opinion of the expert focusing on them and obtain additional hints and explanations, which were particularly useful in the process for searching for the correct answer. The system enabled students to form their own opinions and make notes. Once the case was solved, the system presented the student with an aggregate scorecard acknowledging each stage of the diagnostic and therapeutic process. Results The analysis presented in this paper refers to a 38-year-old female patient. The procedure comprises the analysis of: 1. Expected progression of the case 7 years following the accident. 2. Actual status of the patient with focus on irregularities. 3. Hypothesis concerning the reasons for the observed irregularities. Ad.1. Seven years after a crural fracture, medical examination is expected to reveal the following: 1. Full freedom of motion in proximate joints (knee joint and ankle joint). 2. Full freedom from pain, both at rest and during static and dynamic loading of the lower limb. 3. Restoration of correct (equal) length of the lower limbs. The relative and absolute length should be identical in both legs. 4. Full restoration of muscle mass in the affected leg, with no indication of atrophy. 5. Physical examination of the peripheral nervous system should reveal no sensory or motor dysfunction. Ad.2. The following situation is presented for analysis: 1. Reduced mobility in left ankle joint and left knee joint secondary to fracture. A. Left knee joint: a. Loss of elasticity in periarticular tissues limiting active and passive flexion range of the joint to 90° (lower bound of physiological norm 20°) =1 described as a 30° extension contracture of the left knee (120°­90° 0°). Comparative examination =3 of the right (unaffected) knee reveals articulation range of 160° and suggests that the actual contracture of the left knee is equal to 70° (160°­ 90° 0°). In orthopedic surgery, this is referred =7 to as a 70° loss of range of motion in the left knee joint. The observed extension contracture of the left knee is a direct consequence of cast damage (long-term 30° fixation of knee joint), subpatellar scarring, insufficient kinesiotherapy, and Sudeck's atrophy (complex regional pain syndrome; CRPS). b. Persistent 10° impairment of active and passive extension range in the left knee, described as a 10° flexion contracture of the left knee. This is a direct consequence of cast damage, iatriogenic supracondylar fracture of the tibia with formation of scar tissue in proximity of the patellar tendon, insufficient physiotherapy, loss of elasticity in all periarticular tissues, and the resulting 10° inward rotation of the left foot. Neurogenic drop of the left foot is instinctively compensated for by a 10° contracture of the left knee (righting reflex), which functionally equalizes the length of lower limbs in standstill and during the stance phase of the gait cycle. B. Left ankle joint: a. Loss of active extension (dorsal flexion) in the left ankle joint with a ­10° deficit compared to the "0" position (10° inward rotation of the left foot), caused by confirmed impairment of the left common fibular nerve. b. Restriction of passive extension to 10°, which, compared to the unaffected side (30°), results in a 20° loss of articulation (30°­10° 0°). =2 This is directly caused by impairment of the fibular nerve compounded by long-term application of resin oil dressing with improper 162Jacek et al.: E-learning in medicine (inward) fixation of the left foot (confirmed by photographic evidence). Additionally, scar tissue has been observed in proximity of the rear section of the articular capsule and within the left gastrocnemius muscle together with the adjoining calcaneal tendon. c. Restriction of active and passive extension of the left foot to 30°, compared to 50° in the unaffected foot, resulting in a 20° loss of articulation. This is caused by descending fibrous scarring of the short muscles of the foot secondary to Sudeck's atrophy and also by cast damage compounded by inadequate physiotherapy. d. Pathological articulation in the left knee, detected after removal of the cast with simultaneous preservation of resin oil dressing on the thigh (5 months after corrective surgery) and initial exercises of the affected left knee. The following persistent changes were observed: 1. posterolateral instability of the knee (+reverse pivot shift/Jakob test, +rotation recurvatum test/Hugston test, +apprehension test); 2. medial instability (abduction) ­ I/II° (extension) and II° (30° flexion) 3. lateral instability (adduction) ­ I/II° (extension) and II° (30° flexion) 2. Pain in the left hip associated with changes in atmospheric pressure. Pain in the left leg caused by loading when at standstill and during the gait cycle, as well as during rehabilitation of the knee and ankle joints, triggered by extension of soft tissues. 3. Equal length of both legs (both absolute and relative), evidenced by measurements. 4. Slight muscle loss in the thigh and crural area (muscle mass assessment tests conducted in accordance with Lovett's six-degree scale did not indicate atrophy of the thigh but did reveal class III/IV atrophy of the foot extensor muscles). 5. Damage to the left common fibular nerve presenting with typical impairment of tactile sensation and paresis of the left foot extensor muscles. The case was submitted to a court due to long-term treatment necessitating medical leave. The Social Insurance Institution (ZUS) medical commission found temporary inability to perform work for which the patient is otherwise qualified and awarded the patient with a pension. Ad.3. Medical opinion presented to the court ­ interpretation of the observed anomalies. 1. Restricted articulation in the joints of the left leg (knee and ankle) is associated with long-term application of immobilizing resin dressing (covering the knee for 5 months and fully removed from the crux after 7 months ­ patient's testimony+progression analysis). It should be noted that the primary goal of any surgical intervention in the osteoarticular system is to eliminate the need for external immobilization of the limb, as set forth in the AO osteosynthesis principles formulated in Switzerland at the 1956 orthopedic surgery conference. In addition, the medical rehabilitation of the patient is regarded as inadequate. The overall clinical presentation was aggravated by fibrous changes in periarticular tissues developing as a result of reflex sympathetic dystrophy secondary to trauma. RSD is a set of clinical symptoms first described by Sudeck (a German radiologist) in 1900. 2. Pain experienced by the patient is associated with complex instability of the left knee joint (confirmed by the expert). Repeated loading of the joint led to chondromalacia, i.e., pathological breakdown of cartilage with exposure of nociceptors in the cartilaginous and subcartilaginous cellular layers. Passive and active extension of the flexed articular and periarticular tissues during kinesiotherapy and righting produced pain and led to long-term gait asymmetry, relieving the affected limb but ultimately resulting in chronic muscle-related pain of the sacroiliac joint. 3. Corrective surgery was successful in restoring the correct (equal) length of both legs. 4. The primary cause of muscle mass loss in the crural area of the left leg was long-term immobilization resulting in inaction and muscular atrophy. 5. Torsional injuries to the knee joint are often complicated by damage to the common fibular nerve, producing lateral or posterolateral rotational instability. This is due to overextension exceeding the tolerance thresholds of passive stabilizers ­ the lateral collateral ligament and the lateral meniscus of the joint capsule. Stretching the nerve by 8% has been shown to produce metabolic distress in nerve cells, while 15% is the threshold beyond which structural changes typically occur and may include axonotmesis (disruption of the axon with preservation of the connective tissue sheath) or neurotmesis (complete disruption of the nerve). In the presented case, neurological examination suggested axonotmesis, which was later confirmed by EMG. Jacek et al.: E-learning in medicine163 Progression analysis A ­ analysis of radiological images of the left crux confirms double crural fracture. Contrary, however, to what is suggested in the patient's record and the discharge card, the accident (falling down a flight of stairs) is unlikely to be the sole causative factor. While the primary torsional/ oblique fracture with detachment of a butterfly-shaped wedge was due to torsional forces sustained during the fall, the supracondylar fracture of the tibia with detachment of its anterior tuberosity was instead directly caused by improper insertion of an interlocking intramedullary nail. Accordingly, the court expert attributes the supracondylar fracture of the tibia to medical malpractice on the part of the operating surgeon rather than to the accident suffered by the patient. In addition, the patient was diagnosed with Sudeck's atrophy, which ­ owing to intensive physiotherapy and pharmacological treatment ­ was halted in the second stage (dystrophy) and subsequently went into remission, producing only moderate impairment of the articulation of left knee and ankle joints. In light of the above, the expert's opinion delivered to the Court identifies the following irregularities: 1. The double crural fracture was only partly caused by the original accident (falling down a flight of stairs). While the primary torsional/oblique fracture was due to torsional forces sustained during the fall, the anterior supracondylar fracture of the tibia is an iatrogenic event caused by improper insertion of an interlocking intramedullary nail. 2. Cast damage to the left crux, resulting in restricted extension and flexion ranges of the left knee and ankle joints, was caused by long-term fixation of the left leg (5 months until exposure of the knee; 7 months until complete removal of the dressing), itself forced by the specifics of the applied surgical procedure. 3. The rehabilitation exercises following removal of the dressing were inadequate and ended prematurely. 4. The superficial follow-up examinations coupled with the failure to perform neurological tests resulted in delayed application of physiotherapeutic procedures promoting regeneration of the common fibular nerve (Solux-type thermotherapy, application of peloid and paraffin wax, diathermy, etc.) and counteracting the degeneration of neuromuscular junctions (electrostimulation; passive and active muscle exercises). Excessive focus on cast damage and complications due to Sudeck's atrophy coupled with neglect for neurological problems (with 7 years elapsing before the patient underwent a neurological 5. workup) effectively prevented any form of surgical reconstruction of the fibular nerve. The patient requires further arthroscopic examination of the left knee joint with a view toward surgical reconstruction of the joint, ameliorating its posterolateral instability. Reconstruction of events Initial malpractice occurs during surgery and consists in improper insertion of an intramedullary nailneed for repeat surgery without the option to replace the intramedullary nailneed for an external stabilizer further removed from the fracture zone and failing to ensure adequate immobilization, as well as two AO screws in the fracture zoneunsatisfactory stability of the surgical fixation necessitates highly disadvantageous application of an external resin dressing until union is established (7 months in total)cast damage to left crux (joint contracture; muscle loss)complications caused by the cast further cloud the clinical presentation and conceal pathological articulation of the left knee, which only becomes apparent once the cast is removedworse still, the dropping foot and shuffling gait are initially overlooked and subsequently attributed (incorrectly) to cast damage and Sudeck's atrophy, neglecting the need for a neurological workup and EMG examination, which would confirm damage to the common fibular nerveadditionally, any external immobilization carries a non-negligible risk of Sudeck's atrophy (as indeed observed in the patient); in fact, reflex sympathetic dystrophy has been reported even as a result of trivial finger cuts. Pathophysiological changes in the left crural area ­ Long-term immobilization of the left crux effectively produced a "vicious cycle" of symptoms:joint immobilized atrophy of blood vessels in synovial membrane significant ischemia of synovial membrane reduced filtration pressure insufficient production of synovial fluid articular cartilage deprived of nutrients degeneration of articular cartilage onset of chondromalacia. removal of plaster cast insufficient production of synovial fluid due to atrophy of synovial membrane increased friction mechanical damage to articular cartilage (chondromalacia) further degenerative changes. 164Jacek et al.: E-learning in medicine ­ joint immobilized ischemia of articular capsule degeneration+formation of scar/fibrous tissue joint contracture progressive impairment of joint articulation deepening ischemia joint degeneration. knee joint immobilized loss of muscle mass throughout the lower limb removal of cast loss of dynamic stability in knee joint pathological articulation exceeding physiological limits mechanical damage to articular cartilage (chondromalacia) exposure of nociceptors in the subcartilaginous layer pain associated with articulation reflective voluntary restriction of articulation further muscle loss further loss of joint stability. joint immobilized aggregation of intracapsular fibrin intracapsular thrombosis calcification of suprapatellar bursa by the surgeon who mishandled the insertion of the interlocking intramedullary nail. This caused calcification of periarticular tissues via so-called "cast damage", leading to Sudeck's atrophy and postoperative scarring of the skin and crural tissues, typical in open surgery. In conclusion, the person responsible for winter maintenance of the access staircase can only be held partly responsible for the outcome of the accident. Discussion and conclusions As it was discussed previously by Naveed Saleh, M.D., static patient interactions have been used most frequently in computer-based training. The purpose of a static patient case is to teach students how to ask relevant questions and to order relevant tests in the context of a patient's medical condition. Additionally, the goal of the static patient is to teach students to recognize abnormal findings and to infer a diagnosis followed by development of an appropriate treatment plan [9]. H. Salminen, N. Zary et al. emphasize that virtual patients may support learning processes and be a valuable complement in teaching communication skills, patientcenteredness, clinical reasoning, and reflective thinking, at the same time they point toward the lacks of reports on how to design and use virtual patients with a primary care perspective [10]. Virtual patient software technology offers the distinct advantage of providing more versatility, mobility, and accessibility through a virtual environment that maximizes the realism of actual patient care at a low level of risk, avoiding the need for expanded physical space requirements and the associated overhead and staffing. These simulation scenarios can increase students' exposure to patients living in a range of environments from rural communities to urban locations [11]. Furthermore, the authors of this article point to the fact that static patient interactions may be extremely valuable if presented in a manner which calls for reconstruction of past events. Familiarizing the student with such type of retrospective approach promotes deductive reasoning. The general aim of the authors was to enlarge the students' knowledge concerning orthopedics in a form that would be interesting and at the same time challenging. The authors wanted to see whether students are able to recognize the mistreatment (i.e., incorrect insertion of an intramedullary nail and delayed diagnostics of the common fibular nerve preventing surgical intervention) and combine their medical knowledge with legal hits of Assessment of disability The plaintiff's disability is classified as moderate and caused by impaired mobility (code 05R) and neurological impairment (code 10N), necessitating persistent application of orthosis on the left knee as a precaution against further degenerative changes as well as elastic support of the left ankle joint to dynamically counteract foot drop and prevent "wedging" of the left foot in the swing phase of the gait cycle. Moderate disability is defined as disability which requires conditional and/or temporary assistance during rehabilitation and/or during intensification of symptoms. Persons assigned to this group are only permitted to work under special conditions, in places adapted to their needs. The respondent (employee of a maintenance company) can only be held responsible for neglecting his duty to de-ice the staircase as a result of which the patient sustained compound fracture of her left tibia and fibula, leading to progressive posterolateral instability of the left knee joint. Thorough analysis of the available evidence suggests that while damage to the knee joint did result in damage to the common fibular nerve, the maintenance company cannot be held responsible for this progression as without the plaster cast and the corresponding onset of Sudeck's atrophy, the attending doctors would doubtlessly have been led to suspect damage to the common fibular nerve. Timely neurosurgical intervention coupled with proper neurological and physiotherapeutic treatment would then have been likely to result in full functional restoration of the damaged nerve. In the event, responsibility for the unanticipated (and initially unnecessary) long-term treatment must be borne Jacek et al.: E-learning in medicine165 the medical expert included in the e-platform. The presented case in CASUS system had several distinct advantages. It not only proved that potential of the CASUS system could be adjusted to any training scenario, but the use of modern IT tools is a flexible form of medical knowledge gathering because of data visualization and media aids. In the presented case, in-depth analysis revealed a clear medical malpractice. The specific role of a court-appointed medical expert was to help students during the problemsolving educational process. (The person fulfilling this task had no influence on the treatment process ­ rather, he/she provided an assessment of treatment which had already been concluded.) The expert previously was able to determine which actions and events led to the presented in the e-learning environment state and thanks to this, students could identify symptoms, which should not occur normally during a successful therapy. Students had to perform a retrospective analysis ­ much unlike the standard diagnostic procedure, which is inherently prospective (i.e., determining a course of action and predicting its outcome). This unusual mode of reasoning was an integral aspect of legal proceedings and was for the student a unique challenge. The presented case is interesting as it presents the nonstandard application of medical knowledge. It should be noted that e-learning systems are increasingly being applied in medical curricula all over the world and are usually well received by students. However, they still have to be developed and discussed. For an overview of the available online e-learning platforms, please refer to [12­17]. Conflict of interest statement Authors' conflict of interest disclosure: The authors stated that there are no conflicts of interest regarding the publication of this article. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Bio-Algorithms and Med-Systems de Gruyter

Involvement of medical experts in legal proceedings: an e-learning approach

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Publisher
de Gruyter
Copyright
Copyright © 2014 by the
ISSN
1895-9091
eISSN
1896-530X
DOI
10.1515/bams-2014-0009
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Abstract

E-learning programs based on the "Virtual Patient" paradigm familiarize students with the process of combining information derived from different branches of medical science. In addition, medical practice often requires paralegal knowledge ­ for example, when determining the degree of disability or taking part in medical malpractice proceedings. This paper serves as an introduction to inclusion of modern IT tools in teaching curricula. Such tools are available to almost every student of medical sciences and frequently employ the "Virtual Patient" concept mentioned above. For the purposes of our study, we have prepared a selection of training materials using the CASUS software. The specific features of our study include involvement in legal proceedings based on a retrospective approach, i.e., reconstruction of past events. Keywords: medicine. clinical pathology; E-learning; forensic and parcel of modern medical curricula. Deploying new technologies usually introduces tensions, and e-learning is no exception. Some wish to use it merely to perform preexisting activities more efficiently or faster, others pursue new ways of thinking and working that the use of such technology affords them. For healthcare, e-learning's goal is education, not technology, because the student must be aware that he/she cannot always predict the outcome of a medical case. Sometimes, the physician has to take risks, and "see what happens". Serendipity often adds to the excitement of teaching. It certainly adds to the excitement of learning. The use of technology in support of education is not, therefore, a causal or engineered set of practices; rather, it requires creativity and adaptability in response to the specific and changing contexts in which it is used [1]. In many countries, using e-learning platforms by students turned out to be beneficial. For example, at the University of Müenster, 15 virtual cases of death have been developed by using the web-based Inmedea Simulator, and the overall reception of the program by the medical students resulted to be positive [2]. In Scandinavia at the "Civil and Commercial Law" 4 ECTS course, its organizers adopted a medical VC system to teach law. In the course, the virtual case system Web-SP was used by the students, which originally was developed for healthcare education and offered possibilities to interview the client, perform physical examinations, order lab and imaging tests, plus suggest proper diagnosis and treatment, to teach general law, civil law, real estate law, and construction law. As a result, students wanted more virtual cases like these in the course in their future studies [3]. The experiment described by Kopp et al., a case-based, worked example approach was realized in a computer-based learning environment with the intention of facilitating medical students' diagnostic knowledge turned out to be effective and efficient [4]. Despite this increasing use, the empirical basis for an optimal integration strategy of computerized teaching methods is small for medical education. In addition to general aspects of integrating e-learning into a curriculum, like feasibility, software and content requirements, or curriculum structure, the integration strategy, with respect to motivational aspects and acceptance of DOI 10.1515/bams-2014-0009 Received May 26, 2014; accepted May 26, 2014; previously published online July 4, 2014 Introduction The content of medical learning curricula in Poland are broad, covering such disciplines as anatomy, physiology, biochemistry, histology, biology, pharmacology, pathology, pathophysiology, and many clinical specializations ­ internal diseases, surgery, gynecology, obstetrics, and pediatrics, to name just a few. The student is faced with a generalized or detailed (depending on the chosen specialization) view of the given field ­ such as dermatology, neurology, ophthalmology, otolaryngology, infectious diseases, endocrinology, etc. E-learning applications are part *Corresponding author: Irena Roterman-Konieczna, Department of Bioinformatics and Telemedicine, Medical College, Jagiellonian University, Lazarza 16, 31-530 Cracow, Poland, E-mail: myroterm@cyf-kr.edu.pl Dygut Jacek: Hospital in Przemyl, Przemyl, Poland Sylwia Plonka: Faculty of Physics, Astronomy and Applied Computer Science, Cracow, Poland 160Jacek et al.: E-learning in medicine both students and instructors, and exam-relevance of the content is crucial [5]. In Poland, medical practitioners are often expected to not only apply their professional judgment but also remain capable of justifying their decisions on legal grounds; therefore, the medical training based on the Virtual Patient platform has been extended with legal aspects related to the structure of the healthcare system and patient rights. In addition, the teaching materials were augmented with a section covering materials from court proceedings concerning medical malpractice in both diagnostics and therapy. Virtual patients (VPs) are computer simulations of real-life clinical scenarios created for the purpose of healthcare and medical training, education, or assessment. The case described in this article has been implemented in the CASUS system, which is a web-based VP shell developed by LMU University of Munich and implemented at Jagiellonian University in Poland. The CASUS system enables the authoring of VP cases, course management, as well as the tracing of students' activities [6]. CASUS is a case-based learning system, which is integrated into the medical curriculum of various medical schools [7]. At the University of Munich in Germany, the level of acceptance among participants toward learning with computers, doing computer-based examinations, and the usability of the system in the context of computerized National Boards examinations were examined. Some of the students had concerns about the required technical reliability and data safety of the examination system, but generally, the level of acceptance was high [8]. The platform used at Jagiellonian University in Poland required that medical students combine their professional knowledge in the area of orthopedics with legal experience in order to issue an opinion regarding medical malpractice: the case concerned a female patient with serious complications, which should not normally occur after such a long period of time (a crural fracture caused by falling on a slippery surface should no longer be detectable after 7 years). The student's task was to investigate the case, identify causative factors, and determine the medical malpractice point. Materials and methods Materials The students were presented with the e-learning environment case materials shown on screen cards. Each screen card was an exercise to solve, associated with the discussed complications after a crural fracture. Materials gathered to implement the case in the VP platform were taken from the medical records of the patient (in compliance with applicable personal data protection laws) and transformed into e-files. The materials presented to the student were accompanied with multimedia files: images, video files, as well as expert comments. The general goal of the described-here e-task was to identify the reasons behind the mistreatment of the fracture. The first screen card of the program (Figure 1) served as an "introductory" point of the case. It familiarized the Figure 1Sample screenshot introducing the student to the case in the CASUS system. Jacek et al.: E-learning in medicine161 student with information on the accident and was followed by additional pages with details on the patient's history, diagnostics, therapy, and physical examination. Comments of the medical expert were attached to each page. Seven years after the accident, the patient should have no vivid recollections of the event or the progression of the case. Methods The CASUS system tasks consisted of trial-and-error exercises. Among them, the most common were multiplechoice questions; free-text query; request to underline correct answers; mix-and-match query; free-text query not subject to grading; "lab data" query; "long menu" query; request to fill in gaps in description; request to establish causation. Students could read the opinion of the expert focusing on them and obtain additional hints and explanations, which were particularly useful in the process for searching for the correct answer. The system enabled students to form their own opinions and make notes. Once the case was solved, the system presented the student with an aggregate scorecard acknowledging each stage of the diagnostic and therapeutic process. Results The analysis presented in this paper refers to a 38-year-old female patient. The procedure comprises the analysis of: 1. Expected progression of the case 7 years following the accident. 2. Actual status of the patient with focus on irregularities. 3. Hypothesis concerning the reasons for the observed irregularities. Ad.1. Seven years after a crural fracture, medical examination is expected to reveal the following: 1. Full freedom of motion in proximate joints (knee joint and ankle joint). 2. Full freedom from pain, both at rest and during static and dynamic loading of the lower limb. 3. Restoration of correct (equal) length of the lower limbs. The relative and absolute length should be identical in both legs. 4. Full restoration of muscle mass in the affected leg, with no indication of atrophy. 5. Physical examination of the peripheral nervous system should reveal no sensory or motor dysfunction. Ad.2. The following situation is presented for analysis: 1. Reduced mobility in left ankle joint and left knee joint secondary to fracture. A. Left knee joint: a. Loss of elasticity in periarticular tissues limiting active and passive flexion range of the joint to 90° (lower bound of physiological norm 20°) =1 described as a 30° extension contracture of the left knee (120°­90° 0°). Comparative examination =3 of the right (unaffected) knee reveals articulation range of 160° and suggests that the actual contracture of the left knee is equal to 70° (160°­ 90° 0°). In orthopedic surgery, this is referred =7 to as a 70° loss of range of motion in the left knee joint. The observed extension contracture of the left knee is a direct consequence of cast damage (long-term 30° fixation of knee joint), subpatellar scarring, insufficient kinesiotherapy, and Sudeck's atrophy (complex regional pain syndrome; CRPS). b. Persistent 10° impairment of active and passive extension range in the left knee, described as a 10° flexion contracture of the left knee. This is a direct consequence of cast damage, iatriogenic supracondylar fracture of the tibia with formation of scar tissue in proximity of the patellar tendon, insufficient physiotherapy, loss of elasticity in all periarticular tissues, and the resulting 10° inward rotation of the left foot. Neurogenic drop of the left foot is instinctively compensated for by a 10° contracture of the left knee (righting reflex), which functionally equalizes the length of lower limbs in standstill and during the stance phase of the gait cycle. B. Left ankle joint: a. Loss of active extension (dorsal flexion) in the left ankle joint with a ­10° deficit compared to the "0" position (10° inward rotation of the left foot), caused by confirmed impairment of the left common fibular nerve. b. Restriction of passive extension to 10°, which, compared to the unaffected side (30°), results in a 20° loss of articulation (30°­10° 0°). =2 This is directly caused by impairment of the fibular nerve compounded by long-term application of resin oil dressing with improper 162Jacek et al.: E-learning in medicine (inward) fixation of the left foot (confirmed by photographic evidence). Additionally, scar tissue has been observed in proximity of the rear section of the articular capsule and within the left gastrocnemius muscle together with the adjoining calcaneal tendon. c. Restriction of active and passive extension of the left foot to 30°, compared to 50° in the unaffected foot, resulting in a 20° loss of articulation. This is caused by descending fibrous scarring of the short muscles of the foot secondary to Sudeck's atrophy and also by cast damage compounded by inadequate physiotherapy. d. Pathological articulation in the left knee, detected after removal of the cast with simultaneous preservation of resin oil dressing on the thigh (5 months after corrective surgery) and initial exercises of the affected left knee. The following persistent changes were observed: 1. posterolateral instability of the knee (+reverse pivot shift/Jakob test, +rotation recurvatum test/Hugston test, +apprehension test); 2. medial instability (abduction) ­ I/II° (extension) and II° (30° flexion) 3. lateral instability (adduction) ­ I/II° (extension) and II° (30° flexion) 2. Pain in the left hip associated with changes in atmospheric pressure. Pain in the left leg caused by loading when at standstill and during the gait cycle, as well as during rehabilitation of the knee and ankle joints, triggered by extension of soft tissues. 3. Equal length of both legs (both absolute and relative), evidenced by measurements. 4. Slight muscle loss in the thigh and crural area (muscle mass assessment tests conducted in accordance with Lovett's six-degree scale did not indicate atrophy of the thigh but did reveal class III/IV atrophy of the foot extensor muscles). 5. Damage to the left common fibular nerve presenting with typical impairment of tactile sensation and paresis of the left foot extensor muscles. The case was submitted to a court due to long-term treatment necessitating medical leave. The Social Insurance Institution (ZUS) medical commission found temporary inability to perform work for which the patient is otherwise qualified and awarded the patient with a pension. Ad.3. Medical opinion presented to the court ­ interpretation of the observed anomalies. 1. Restricted articulation in the joints of the left leg (knee and ankle) is associated with long-term application of immobilizing resin dressing (covering the knee for 5 months and fully removed from the crux after 7 months ­ patient's testimony+progression analysis). It should be noted that the primary goal of any surgical intervention in the osteoarticular system is to eliminate the need for external immobilization of the limb, as set forth in the AO osteosynthesis principles formulated in Switzerland at the 1956 orthopedic surgery conference. In addition, the medical rehabilitation of the patient is regarded as inadequate. The overall clinical presentation was aggravated by fibrous changes in periarticular tissues developing as a result of reflex sympathetic dystrophy secondary to trauma. RSD is a set of clinical symptoms first described by Sudeck (a German radiologist) in 1900. 2. Pain experienced by the patient is associated with complex instability of the left knee joint (confirmed by the expert). Repeated loading of the joint led to chondromalacia, i.e., pathological breakdown of cartilage with exposure of nociceptors in the cartilaginous and subcartilaginous cellular layers. Passive and active extension of the flexed articular and periarticular tissues during kinesiotherapy and righting produced pain and led to long-term gait asymmetry, relieving the affected limb but ultimately resulting in chronic muscle-related pain of the sacroiliac joint. 3. Corrective surgery was successful in restoring the correct (equal) length of both legs. 4. The primary cause of muscle mass loss in the crural area of the left leg was long-term immobilization resulting in inaction and muscular atrophy. 5. Torsional injuries to the knee joint are often complicated by damage to the common fibular nerve, producing lateral or posterolateral rotational instability. This is due to overextension exceeding the tolerance thresholds of passive stabilizers ­ the lateral collateral ligament and the lateral meniscus of the joint capsule. Stretching the nerve by 8% has been shown to produce metabolic distress in nerve cells, while 15% is the threshold beyond which structural changes typically occur and may include axonotmesis (disruption of the axon with preservation of the connective tissue sheath) or neurotmesis (complete disruption of the nerve). In the presented case, neurological examination suggested axonotmesis, which was later confirmed by EMG. Jacek et al.: E-learning in medicine163 Progression analysis A ­ analysis of radiological images of the left crux confirms double crural fracture. Contrary, however, to what is suggested in the patient's record and the discharge card, the accident (falling down a flight of stairs) is unlikely to be the sole causative factor. While the primary torsional/ oblique fracture with detachment of a butterfly-shaped wedge was due to torsional forces sustained during the fall, the supracondylar fracture of the tibia with detachment of its anterior tuberosity was instead directly caused by improper insertion of an interlocking intramedullary nail. Accordingly, the court expert attributes the supracondylar fracture of the tibia to medical malpractice on the part of the operating surgeon rather than to the accident suffered by the patient. In addition, the patient was diagnosed with Sudeck's atrophy, which ­ owing to intensive physiotherapy and pharmacological treatment ­ was halted in the second stage (dystrophy) and subsequently went into remission, producing only moderate impairment of the articulation of left knee and ankle joints. In light of the above, the expert's opinion delivered to the Court identifies the following irregularities: 1. The double crural fracture was only partly caused by the original accident (falling down a flight of stairs). While the primary torsional/oblique fracture was due to torsional forces sustained during the fall, the anterior supracondylar fracture of the tibia is an iatrogenic event caused by improper insertion of an interlocking intramedullary nail. 2. Cast damage to the left crux, resulting in restricted extension and flexion ranges of the left knee and ankle joints, was caused by long-term fixation of the left leg (5 months until exposure of the knee; 7 months until complete removal of the dressing), itself forced by the specifics of the applied surgical procedure. 3. The rehabilitation exercises following removal of the dressing were inadequate and ended prematurely. 4. The superficial follow-up examinations coupled with the failure to perform neurological tests resulted in delayed application of physiotherapeutic procedures promoting regeneration of the common fibular nerve (Solux-type thermotherapy, application of peloid and paraffin wax, diathermy, etc.) and counteracting the degeneration of neuromuscular junctions (electrostimulation; passive and active muscle exercises). Excessive focus on cast damage and complications due to Sudeck's atrophy coupled with neglect for neurological problems (with 7 years elapsing before the patient underwent a neurological 5. workup) effectively prevented any form of surgical reconstruction of the fibular nerve. The patient requires further arthroscopic examination of the left knee joint with a view toward surgical reconstruction of the joint, ameliorating its posterolateral instability. Reconstruction of events Initial malpractice occurs during surgery and consists in improper insertion of an intramedullary nailneed for repeat surgery without the option to replace the intramedullary nailneed for an external stabilizer further removed from the fracture zone and failing to ensure adequate immobilization, as well as two AO screws in the fracture zoneunsatisfactory stability of the surgical fixation necessitates highly disadvantageous application of an external resin dressing until union is established (7 months in total)cast damage to left crux (joint contracture; muscle loss)complications caused by the cast further cloud the clinical presentation and conceal pathological articulation of the left knee, which only becomes apparent once the cast is removedworse still, the dropping foot and shuffling gait are initially overlooked and subsequently attributed (incorrectly) to cast damage and Sudeck's atrophy, neglecting the need for a neurological workup and EMG examination, which would confirm damage to the common fibular nerveadditionally, any external immobilization carries a non-negligible risk of Sudeck's atrophy (as indeed observed in the patient); in fact, reflex sympathetic dystrophy has been reported even as a result of trivial finger cuts. Pathophysiological changes in the left crural area ­ Long-term immobilization of the left crux effectively produced a "vicious cycle" of symptoms:joint immobilized atrophy of blood vessels in synovial membrane significant ischemia of synovial membrane reduced filtration pressure insufficient production of synovial fluid articular cartilage deprived of nutrients degeneration of articular cartilage onset of chondromalacia. removal of plaster cast insufficient production of synovial fluid due to atrophy of synovial membrane increased friction mechanical damage to articular cartilage (chondromalacia) further degenerative changes. 164Jacek et al.: E-learning in medicine ­ joint immobilized ischemia of articular capsule degeneration+formation of scar/fibrous tissue joint contracture progressive impairment of joint articulation deepening ischemia joint degeneration. knee joint immobilized loss of muscle mass throughout the lower limb removal of cast loss of dynamic stability in knee joint pathological articulation exceeding physiological limits mechanical damage to articular cartilage (chondromalacia) exposure of nociceptors in the subcartilaginous layer pain associated with articulation reflective voluntary restriction of articulation further muscle loss further loss of joint stability. joint immobilized aggregation of intracapsular fibrin intracapsular thrombosis calcification of suprapatellar bursa by the surgeon who mishandled the insertion of the interlocking intramedullary nail. This caused calcification of periarticular tissues via so-called "cast damage", leading to Sudeck's atrophy and postoperative scarring of the skin and crural tissues, typical in open surgery. In conclusion, the person responsible for winter maintenance of the access staircase can only be held partly responsible for the outcome of the accident. Discussion and conclusions As it was discussed previously by Naveed Saleh, M.D., static patient interactions have been used most frequently in computer-based training. The purpose of a static patient case is to teach students how to ask relevant questions and to order relevant tests in the context of a patient's medical condition. Additionally, the goal of the static patient is to teach students to recognize abnormal findings and to infer a diagnosis followed by development of an appropriate treatment plan [9]. H. Salminen, N. Zary et al. emphasize that virtual patients may support learning processes and be a valuable complement in teaching communication skills, patientcenteredness, clinical reasoning, and reflective thinking, at the same time they point toward the lacks of reports on how to design and use virtual patients with a primary care perspective [10]. Virtual patient software technology offers the distinct advantage of providing more versatility, mobility, and accessibility through a virtual environment that maximizes the realism of actual patient care at a low level of risk, avoiding the need for expanded physical space requirements and the associated overhead and staffing. These simulation scenarios can increase students' exposure to patients living in a range of environments from rural communities to urban locations [11]. Furthermore, the authors of this article point to the fact that static patient interactions may be extremely valuable if presented in a manner which calls for reconstruction of past events. Familiarizing the student with such type of retrospective approach promotes deductive reasoning. The general aim of the authors was to enlarge the students' knowledge concerning orthopedics in a form that would be interesting and at the same time challenging. The authors wanted to see whether students are able to recognize the mistreatment (i.e., incorrect insertion of an intramedullary nail and delayed diagnostics of the common fibular nerve preventing surgical intervention) and combine their medical knowledge with legal hits of Assessment of disability The plaintiff's disability is classified as moderate and caused by impaired mobility (code 05R) and neurological impairment (code 10N), necessitating persistent application of orthosis on the left knee as a precaution against further degenerative changes as well as elastic support of the left ankle joint to dynamically counteract foot drop and prevent "wedging" of the left foot in the swing phase of the gait cycle. Moderate disability is defined as disability which requires conditional and/or temporary assistance during rehabilitation and/or during intensification of symptoms. Persons assigned to this group are only permitted to work under special conditions, in places adapted to their needs. The respondent (employee of a maintenance company) can only be held responsible for neglecting his duty to de-ice the staircase as a result of which the patient sustained compound fracture of her left tibia and fibula, leading to progressive posterolateral instability of the left knee joint. Thorough analysis of the available evidence suggests that while damage to the knee joint did result in damage to the common fibular nerve, the maintenance company cannot be held responsible for this progression as without the plaster cast and the corresponding onset of Sudeck's atrophy, the attending doctors would doubtlessly have been led to suspect damage to the common fibular nerve. Timely neurosurgical intervention coupled with proper neurological and physiotherapeutic treatment would then have been likely to result in full functional restoration of the damaged nerve. In the event, responsibility for the unanticipated (and initially unnecessary) long-term treatment must be borne Jacek et al.: E-learning in medicine165 the medical expert included in the e-platform. The presented case in CASUS system had several distinct advantages. It not only proved that potential of the CASUS system could be adjusted to any training scenario, but the use of modern IT tools is a flexible form of medical knowledge gathering because of data visualization and media aids. In the presented case, in-depth analysis revealed a clear medical malpractice. The specific role of a court-appointed medical expert was to help students during the problemsolving educational process. (The person fulfilling this task had no influence on the treatment process ­ rather, he/she provided an assessment of treatment which had already been concluded.) The expert previously was able to determine which actions and events led to the presented in the e-learning environment state and thanks to this, students could identify symptoms, which should not occur normally during a successful therapy. Students had to perform a retrospective analysis ­ much unlike the standard diagnostic procedure, which is inherently prospective (i.e., determining a course of action and predicting its outcome). This unusual mode of reasoning was an integral aspect of legal proceedings and was for the student a unique challenge. The presented case is interesting as it presents the nonstandard application of medical knowledge. It should be noted that e-learning systems are increasingly being applied in medical curricula all over the world and are usually well received by students. However, they still have to be developed and discussed. For an overview of the available online e-learning platforms, please refer to [12­17]. Conflict of interest statement Authors' conflict of interest disclosure: The authors stated that there are no conflicts of interest regarding the publication of this article. Research funding: None declared. Employment or leadership: None declared. Honorarium: None declared.

Journal

Bio-Algorithms and Med-Systemsde Gruyter

Published: Sep 30, 2014

References