Challenges in designing a Virtual Emotive Patient Avatar (VEPA) for simulation-based clinical history taking skills practice

Background:
Conventionally, history taking in clinical skills learning has always been conducted with the use of a standardized patient (SP), mannequin, a real patient, or even simulation-based however using these mediums to simulate the clinical examination process results in many issues such as low realism of clinical signs, lack of communication with the patient (with mannequins), health risks to students and SPs, discomfort to the SP or real patient, and changes in standardization due to the SP repeating the same voice lines and actions for the clinical simulation process. Simulation-based clinical skills training with computer and physical models could be a viable alternative to the use of real patients, however, this eliminates the element of human interaction with the patient. Most of these conventional methods also require access to the campus or hospitals, which students may not have access to due to lockdowns, especially during the COVID-19 pandemic. Therefore an alternative learning platform is required to allow students to practice history taking remotely while maintaining a high realism. To resolve these issues, some studies have utilized virtual patients for students to practice clinical skills. However simulating a patient’s history through a talking Avatar - a virtual patient avatar is quite challenging – which needs to be explored further.
Objective:
The objective of this research is to review the existing use of virtual patients for learning medical history taking skills, some of them which utilized virtual reality (VR) and augmented reality (AR), and fill up the research gaps in these studies by designing our own AR mobile app with a Virtual Emotive Patient Avatar (VEPA), while outlining the challenges and issues faced when creating the avatar along with the limitation of the VEPA.
Methodology:
In this paper, we review studies that have implemented virtual patients for medical students to practice history taking skills, and discuss how some of these challenges can be addressed in designing our own AR mobile app with a virtual patient, also known as Virtual Emotive Patient Avatar (VEPA) incorporating a history taking module to the mobile app, allowing students to practice history taking in a virtual 3D AR hospital environment. We also reflect and explore further the limitations of such a VEPA app compared to actual clinical skills practice with SP.
Results and discussion:
The review highlighted the research gaps such as overpriced simulation equipment, unsuitability for remote use and lack of AR/AR clinical signs. However, there were some challenges and issues encountered when designing the VEPA, some of which are also unresolved at the moment in existing commercial virtual patients. For example, the patient needs to display emotions and verbal cues (e.g. eye movements or hand gestures) which resemble the actual problem that the patient is having.
Conclusion:
These issues are being tried to be resolved with the VEPA app that is being designed by the authors. Further improvements are being planned in the design of the app to resolve its limitations to allow students to practice clinical skills with higher fidelity to actual clinical skills training in the classroom.