Cover Stories June 2016 Special Section

Paradigm Shift in Medical Education

Written By: Chris Eversole

In four short years, Gainesville-based Shadow Health has taken medical education by storm.

Its cloud-based animated patients captivate students studying nursing, pharmacy, and medicine who grew up in the Digital Age, helping them learn to assess patients, diagnose illnesses and prescribe treatments.

Shadow Health has built its success with investment from 30 families of local “angel investors,” eschewing the strings that come attached to venture capital, said Chief Marketing Officer Rob Kade.

The company has grown from three to 60 employees since opening in 2012, hopping around town to keep up with its growth — starting at the Innovation Hub at the University of Florida and then moving to the former Rice Hardware Store on Southwest First Avenue.

It has landed on the second floor of Union Street Station, the four-story retail, office, and condo building between the Hampton Inn and the Sun Center.

Casually dressed employees grouped in teams situated in open spaces
are adapting to the ever-expanding possibilities of the company’s product.

“We can be agile because we’re cloud- based,” said Educational Coordinator Linda Nichols. “We couldn’t do that if we had everything on a disc.”

The growth exceeds the expectations of Co-Founder and CEO David Massias.

“I’m in awe every day,” he said.

Part of what’s awe-inspiring is sales growth: 178 percent from 2013 to 2014, followed by 129 percent. This year’s growth is projected to be 60 percent.

Also remarkable is product expansion. Shadow Health started out with Tina, a 29-year-old computer-generated patient with uncontrolled diabetes and asthma.

As teaching needs expanded, the company added patients with specialized characteristics, including the following:

  • John Larsen, a 46-year-old recovering from knee surgery
  • Esther Park, a 78-year-old who is having abdominal pain and experiencing irregularity
  • Rachel Adler, a 16-year-old adolescent who is coming in for a routine checkup
  • Danny Rivera, an 8-year-old boy who has had a cough for several days

Shadow Health serves 1,000 schools in the United States and 40 in Canada, and it expects to reach 100,000 students by the end of 2016, Kade said.

The potential is unlimited, Massias said. Although the first customers were nursing schools, Shadow Health now also serves pharmacy schools and physician assistant programs.

Shadow Health is working well for the UF College of Pharmacy, said Karen Sando, a clinical assistant professor.

The college conducted a study of 34 students who used Tina when learning to do health assessments. The results showed a statistically significant increase in the students’ confidence.

“The students like that Tina doesn’t get mad at them if they ask her the same question multiple times,” Sando said.

This summer, the college will start comparing its students’ performance with Tina to the performance of other students nationally.

“It’s a big deal to be able to see how well we’re doing,” Sando said.

The company recently added the School of Health at Uludag University in Turkey.

“We met them at a conference and then did a virtual demo,” Kade said. “They were ready to go.”

Shadow Health is working with hospitals to provide on-the-job training, and it is helping a nursing school revamp its entire curriculum to employ interactive tools broadly.

With growth, Massias’ role has changed.

“At the start, I led by doing,” he said. “Now, I lead by listening. I’m serving our customers by serving our team.”


Ben Lok, Ph.D., a UF computer and information sciences and engineering professor, began working on the Shadow Health approach in 2004, with help from federal funding.

Lok and Aaron Kotranza, who was Lok’s graduate assistant at the time, asked the UF Office of Technology Licensing for help commercializing their research.

OTL introduced them to Massias, a serial entrepreneur who previously worked with a venture capital rm on Wall Street.

Lok remains an adviser to Shadow Health, and Kotranza is the company’s chief technology officer.

The company has grown with local talent lling its diverse needs, which go well beyond computer programming. Positions include training, customer support and marketing.

Content Developer Andrew Donovan has a bachelor’s degree in creative writing from Purdue and a UF master of fine arts degree in poetry.

“I write dialogue to make the patients seem more realistic — including expressing their fears,” he said.

Voice actors are used to bring Donovan’s scripts to life. He also spent time at a pediatrician’s o ce when developing dialogue for Danny.

“I thought children would be withdrawn,” he said. “It was illuminating that they were very forthcoming.”

Shadow Health sta is also helping grow the next generation of Gainesville’s creative talent by volunteering at the Professional Academies Magnet at Loften High School.

The company is guided by its vision of creating “a healthy global population unleashed to its greatest good through healthcare education technology,” Massias said.

“We focus on taking intentional acts to make sure that we play our part in making the world a better place,” he said.


Beginning nursing students at the University of South Florida don’t like Tina at first.

“They’re wet behind the ears, and they complain that she doesn’t answer questions the way they want her to,” said Cheryl Wilson, an assistant professor of nursing and the director of the graduate adult-gerontology primary care concentration.

Wilson asks if the students expect that every patient will be comfortable with their communication styles.

“They respond, ‘I never thought of that,’” she said. “They have to learn to tailor their communication style to each patient.”

The students change their tune.

“I hear them talking in the halls about what Tina said,” Wilson said. “By the end of the semester, they say, ‘I really learned a lot.’”

Shadow Health is so effective in teaching medical assessment that USF has eliminated a textbook on the subject and instead charges a fee for the patient simulation.

“They come out ahead financially,” Wilson said.

Shadow Health benefits faculty.

“When we send students out in the field to do clinicals, there are all sorts of patients — cooperative and uncooperative,” Wilson explained. “With Shadow Health, the patients are standardized.

“We know what the answers are. We can see the students’ growth in thinking like a nurse.”

USF also uses Shadow Health with registered nurses who are taking graduate courses to become nurse practitioners.

The graduate students are learning a different role — one in which they are diagnosing and prescribing.

“They need to gather more information than a nurse does,” Wilson said. “Shadow Health helps them learn to make judgments and think critically.” Wilson started using Shadow Health in 2013, and she’s seen it get better and better over time.

“The patients are constantly learning,” she said. “Every time a student uses a new word, they add it to their vocabulary.”

Grading has become streamlined. At first, instructors had to read every student entry. Now, the program looks for key words in student responses in grading them.

Wilson was impressed by Shadow Health’s development of a 3D representation showing the internal workings of the heart, lungs and abdomen.

“These are great,” she said. “You can’t get a feeling of how the heart ts into the chest through a 2D picture.”

Shadow Health meets students’ expectations, too.

“We have to be very creative to keep the attention of millennials,” Wilson said. “All they’ve known is the digital world.”


Cory Collins is an animator extraordinaire with 20 years of experience in films and gaming — who now animates Shadow Health patients.

Bringing to life the company’s virtual patients in great detail is his most challenging and rewarding work ever, he said.

He enables students to use an otoscope to zoom into the inner ear’s bony labyrinth, probe the nostrils (even see mucus), and view the heart and lungs in 3D. When they shine an exam light into the eye, the pupil dilates.

Collins turns to medical books for reference material and then runs his drawings by Shadow Health’s medical educators. He then coordinates his drawing with programmers.

He also draws exam rooms, reception areas where patients ll out paperwork, medical instruments and medical personnel — keeping a consistent color scheme.

“I have to be artistic while being medically accurate,” he said.

Collins continuously upgrades the arsenal of tools; the latest is a motion capture that records the movement of medical practitioners, creating a realistic pace of movements.

“This is more satisfying than anything I’ve ever done before,” he said. “I’m not just providing entertainment. At the end of the day, I know I’m having a positive impact.”

Collins moved to Gainesville in 2008 to work for a gaming company. Among his games were “Hell Comes to Frogtown.”

Now, Collins also draws detailed realistic images for the company’s anatomy class program.

“I’m really proud of what we do and how we do it,” Collins said. “David’s vision inspires us all.”

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