Clinical reasoning: What do nurses, physicians, and students reason about

Clinical reasoning is a core ability in the health professions, but the term is conceptualised in multiple ways within and across professions. For interprofessional teamwork it is indispensable to recognise the differences in understanding between professions. Therefore, our aim was to investigate how nurses, physicians, and medical and nursing students define clinical reasoning. We conducted 43 semi-structured interviews with an interprofessional group from six countries and qualitatively analysed their definitions of clinical reasoning based on a coding guide. Our results showed similarities across professions, such as the emphasis on clinical skills as part of clinical reasoning. But we also revealed differences, such as a more patient-centered view and a broader understanding of the clinical reasoning concept in nurses and nursing students. The explicit sharing and discussion of differences in the understanding of clinical reasoning across health professions can provide valuable insights into the perspectives of different team members on clinical practice and education. This understanding may lead to improved interprofessional collaboration, and our study's categories and themes can serve as a basis for such discussions.

Medical education in times of war: a mixed-methods needs analysis at Ukrainian medical schools

BACKGROUND

As Ukraine struggles with the education of healthcare professionals due to the war, we aimed to identify the specific effects of the war on medical education, the resulting needs, and the expected consequences for schools, faculty, staff, students, and the healthcare system.

METHODS

In October and November 2022, we performed a survey of students, faculty, and staff of medical schools in Ukraine and conducted semi-structured interviews with faculty leaders (i.e., rectors, vice-rectors). We conducted a descriptive analysis of the survey's closed-ended questions. The survey and the interviews included open-ended questions about war-related restrictions to teaching and learning, resulting needs, and expected consequences, for which we applied a thematic analysis.

RESULTS

We received 239 survey responses (N = 49 faculty and staff, N = 190 students) and conducted nine interviews with faculty leaders across Ukraine. Most survey participants indicated that they had experienced restrictions or changes to their work or study due to the war (86% of faculty and staff, 69% of students). From the thematic analysis of the survey and interviews, we identified eight themes: disruption of teaching, increased workload, mental stress, financial restrictions, non-war related needs, international cooperation, quality of education, and prospects of future professionals. The quality of healthcare education in Ukraine was threatened, and schools, faculty, staff, and students were under great strain. While already established international cooperation has been supportive, some needs have still not been addressed.

CONCLUSIONS

We hope that our findings will help researchers and educators from abroad contribute to meeting Ukraine's needs in medical education.

The association between quality of connections and diagnostic accuracy in student-generated concept maps for clinical reasoning education with virtual patients

Objectives

Concept maps are a learning tool that fosters clinical reasoning skills in healthcare education. They can be developed by students in combination with virtual patients to create a visual representation of the clinical reasoning process while solving a case. However, in order to optimize feedback, there is a need to better understand the role of connections between concepts in student-generated maps. Therefore, in this study we investigated whether the quality of these connections is indicative of diagnostic accuracy.

Methods

We analyzed 40 concept maps created by fifth-year medical students in the context of four virtual patients with commonly encountered diagnoses. Half of the maps were created by students who made a correct diagnosis on the first attempt; the other half were created by students who made an error in their first diagnosis. The connections in the maps were rated by two reviewers using a relational scoring system. Analysis of covariance was employed to examine the difference in mean connection scores among groups while controlling for the number of connections.

Results

There were no differences between the groups in the number of concepts or connections in the maps; however, maps made by students who made a correct first diagnosis had higher scores for the quality of connections than those created by students who made an incorrect first diagnosis (12.13 vs 9.09; p=0.03). We also observed students' general reluctance to use connections in their concept maps.

Conclusion

Our results suggest that the quality, not the quantity, of connections in concept maps is indicative of their diagnostic accuracy.

Developing a European longitudinal and interprofessional curriculum for clinical reasoning

Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching.

Differences in clinical reasoning between female and male medical students

Background

In undergraduate medical education virtual patients (VPs) are a suitable method to teach clinical reasoning and support the visualization of this thinking process in a safe environment. The aim of our study was to investigate differences in the clinical reasoning process and diagnostic accuracy of female and male medical students.

Methods

During the summer term 2020, we provided access to 15 VPs for undergraduate students enrolled in a medical school in Bavaria, Germany. All interactions of the 179 learners within the VP system CASUS were recorded, exported, and analyzed.

Results

We found significant differences in the clinical reasoning of female and male learners. Female students documented more findings, differential diagnoses, tests, and treatment options and more often created a summary statement about the VP. Their overall performance was higher than those of their male peers, but we did not see any significant differences in diagnostic accuracy.

Conclusions

The significant differences between male and female medical students should be considered when planning teaching and research activities. A future study should investigate whether these differences can also be found in physicians.

Publication activities relating to digital teaching and learning in the GMS Journal for Medical Education - a descriptive analysis (1984-2020)

AIMS AND OBJECTIVES

Digital teaching, learning and assessment have been part of medical education and continuing education for decades. The objective of this review paper is to highlight developments and perspectives in these areas in the GMS Journal for Medical Education (GMS JME).

METHODOLOGY

In the spring of 2020, we conducted a systematic literature search of the Journal for Medical Education (JME) and analysed the articles with regard to different categories such as article type, digital tools used or mode of data collection.

RESULTS

Of the 132 articles analysed, 78 were digital interventions (53 of which were exploratory-descriptive), 28 were project descriptions, 16 were surveys of needs or equipment and 10 were concept papers. About one-third of the studies and project reports each dealt with virtual patients or case-based learning, whereas no articles were published on trends such as serious games or virtual reality. Overall, our analysis shows that in many respects, the studies on digital teaching were more broadly based, especially between 2006 and 2010, after which this trend tended to decline again.

CONCLUSIONS

Our analysis shows that publications in the JME consider some key aspects of digital teaching in medical education and continuing education, such as educational videos or virtual patients. The variability of information and methods of presentation advocate the use of guidelines to optimise the quality of scientific papers. Furthermore, clues for future research topics and experimental study designs are identified.

Implementing Remote Collaboration in a Virtual Patient Platform: Usability Study

BACKGROUND

Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the potential learning benefits of collaborative versus individual learning.

OBJECTIVE

This paper describes the implementation of student collaboration in a virtual patient platform. Our aim was to allow pairs of students to communicate remotely with each other during virtual patient learning sessions. We hypothesized that we could provide a collaborative tool that did not impair the usability of the system compared to individual learning and that this would lead to better diagnostic accuracy for the pairs of students.

METHODS

Implementing the collaboration tool had five steps: (1) searching for a suitable software library, (2) implementing the application programming interface, (3) performing technical adaptations to ensure high-quality connections for the users, (4) designing and developing the user interface, and (5) testing the usability of the tool in 270 virtual patient sessions. We compared dyad to individual diagnostic accuracy and usability with the 10-item System Usability Scale.

RESULTS

We recruited 137 students who worked on 6 virtual patients. Out of 270 virtual patient sessions per group (45 dyads times 6 virtual patients, and 47 students working individually times 6 virtual patients minus 2 randomly selected deleted sessions) the students made successful diagnoses in 143/270 sessions (53%, SD 26%) when working alone and 192/270 sessions (71%, SD 20%) when collaborating (P=.04, η²=0.12). A usability questionnaire given to the students who used the collaboration tool showed a usability score of 82.16 (SD 1.31), representing a B+ grade.

CONCLUSIONS

The collaboration tool provides a generic approach for collaboration that can be used with most virtual patient systems. The collaboration tool helped students diagnose virtual patients and had good overall usability. More broadly, the collaboration tool will provide an array of new possibilities for researchers and medical educators alike to design courses for collaborative learning with virtual patients.

How is the situation of women in leadership positions in medical education in Germany?

In Germany, about two thirds of students and doctoral candidates in medicine are female. The proportion is only about 35% for post-doctoral degrees and much lower for many leadership positions at medical schools and on medical education committees. Although reasons for this have long been known, changes are slow in coming. Therefore, with this commentary, we would like to shed light on the current situation regarding gender equality in Germany in medical education and identify and discuss measures. These include, for example, mentoring and networking programs as well as greater consideration of women in committees.

Development and implementation of an online platform for curriculum mapping in medical education

Objectives

Nowadays universities face ever-increasing demands on quality of education, which is crucial from perspective of future graduates. In face of the need of constant quality improvements of medical curricula, it is important to seek strategies for their efficient management. The general trend is to develop electronic support tools to streamline the curricular design, analysis and harmonization.

Methods

Based on the requirements we have identified by the needs analysis among curriculum designers, teachers and managers at five universities involved in the Building Curriculum Infrastructure in Medical Education (BCIME) project, and evidence published in literature on curriculum development, we have developed methodological guidelines on curriculum innovations and a software-based tools that help manage, map and analyse curricula in the medical and healthcare study fields.

Results

In this paper, we share our experiences with building and implementation of EDUportfolio, an online platform developed within our consortium and intended to facilitate harmonisation and optimisation of medical outcome-based curricula. Its functionalities and outputs were verified by pilot mapping of Anatomy curricula as taught at partner universities in five European countries.

Conclusions

The visualisation and the analysis of described curriculum data using natural language processing techniques revealed both the hidden relations between curriculum building blocks and a set of overlaps and gaps in curricula. In addition, we demonstrate both the usability of the platform in the context of the involved academic environments and the capability to map and compare curricula across different institutions and different countries.

Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators

BACKGROUND

Effective clinical reasoning is a core competency of health professionals that is necessary to assure patients' safety. Unfortunately, adoption of longitudinal clinical reasoning curricula is still infrequent. This study explores the barriers that hinder the explicit teaching of clinical reasoning from a new international perspective.

METHODS

The context of this study was a European project whose aim is to develop a longitudinal clinical reasoning curriculum. We collected data in semi-structured interviews with responders from several European countries who represent various health professions and have different backgrounds, roles and experience. We performed a qualitative content analysis of the gathered data and constructed a coding frame using a combined deductive/inductive approach. The identified themes were validated by parallel coding and in group discussions among project members.

RESULTS

A total of 29 respondents from five European countries participated in the interviews; the majority of them represent medicine and nursing sciences. We grouped the identified barriers into eight general themes: Time, Culture, Motivation, Clinical Reasoning as a Concept, Teaching, Assessment, Infrastructure and Others. Subthemes included issues with discussing errors and providing feedback, awareness of clinical reasoning teaching methods, and tensions between the groups of professionals involved.

CONCLUSIONS

This study provides an in-depth analysis of the barriers that hinder the teaching of explicit clinical reasoning. The opinions are presented from the perspective of several European higher education institutions. The identified barriers are complex and should be treated holistically due to the many interconnections between the identified barriers. Progress in implementation is hampered by the presence of reciprocal causal chains that aggravate this situation. Further research could investigate the perceptual differences between health professions regarding the barriers to clinical reasoning. The collected insights on the complexity and diversity of these barriers will help when rolling out a long-term agenda for overcoming the factors that inhibit the implementation of clinical reasoning curricula.

Clinical Reasoning Needs to Be Explicitly Addressed in Health Professions Curricula: Recommendations from a European Consortium

Clinical reasoning entails the application of knowledge and skills to collect and integrate information, typically with the goal of arriving at a diagnosis and management plan based on the patient's unique circumstances and preferences. Evidence-informed, structured, and explicit teaching and assessment of clinical reasoning in educational programs of medical and other health professions remain unmet needs. We herein summarize recommendations for clinical reasoning learning objectives (LOs), as derived from a consensus approach among European and US researchers and health professions educators. A four-step consensus approach was followed: (1) identification of a convenience sample of the most relevant and applied national LO catalogues for health professions educational programs (N = 9) from European and US countries, (2) extraction of LOs related to clinical reasoning and translation into English, (3) mapping of LOs into predefined categories developed within the Erasmus+ Developing, implementing, and disseminating an adaptive clinical reasoning curriculum for healthcare students and educators (DID-ACT) consortium, and (4) synthesis of analysis findings into recommendations for how LOs related to clinical reasoning could be presented and incorporated in LO catalogues, upon consensus. Three distinct recommendations were formulated: (1) make clinical reasoning explicit, (2) emphasize interprofessional and collaboration aspects of clinical reasoning, and (3) include aspects of teaching and assessment of clinical reasoning. In addition, the consortium understood that implementation of bilingual catalogues with English as a common language might contribute to lower heterogeneity regarding amount, structure, and level of granularity of clinical reasoning LOs across countries. These recommendations will hopefully motivate and guide initiatives towards the implementation of LOs related to clinical reasoning in existing and future LO catalogues.

Adaptation of an international virtual patient collection to the COVID-19 pandemic

The COVID-19 pandemic posed new global challenges for teaching. We met these challenges as an international collaboration by adapting a collection of virtual patients for clinical reasoning training to this novel context.

Automatic analysis of summary statements in virtual patients - a pilot study evaluating a machine learning approach

BACKGROUND

The ability to compose a concise summary statement about a patient is a good indicator for the clinical reasoning abilities of healthcare students. To assess such summary statements manually a rubric based on five categories - use of semantic qualifiers, narrowing, transformation, accuracy, and global rating has been published. Our aim was to explore whether computer-based methods can be applied to automatically assess summary statements composed by learners in virtual patient scenarios based on the available rubric in real-time to serve as a basis for immediate feedback to learners.

METHODS

We randomly selected 125 summary statements in German and English composed by learners in five different virtual patient scenarios. Then we manually rated these statements based on the rubric plus an additional category for the use of the virtual patients' name. We implemented a natural language processing approach in combination with our own algorithm to automatically assess 125 randomly selected summary statements and compared the results of the manual and automatic rating in each category.

RESULTS

We found a moderate agreement of the manual and automatic rating in most of the categories. However, some further analysis and development is needed, especially for a more reliable assessment of the factual accuracy and the identification of patient names in the German statements.

CONCLUSIONS

Despite some areas of improvement we believe that our results justify a careful display of the computer-calculated assessment scores as feedback to the learners. It will be important to emphasize that the rating is an approximation and give learners the possibility to complain about supposedly incorrect assessments, which will also help us to further improve the rating algorithms.

The online inverted classroom model (oICM). A blueprint to adapt the inverted classroom to an online learning setting in medical and health education

This article was migrated. The article was marked as recommended. The idea of this paper is to offer a blueprint, with that facilitators have a guide to set up a complete digital teaching scenario according to the latest insights of didactical research. The corona pandemic forced higher education institutions all around the world to radically shift their curricula from a mix of face-to-face and remote teaching methods to a fully remote curriculum. Though challenging, this time provides opportunities to implement new educational methods and improve the quality of digital teaching. The classical concept of the inverted classroom was modified to meet the special needs of online settings. The proposed online Inverted Classroom Model (oICM) includes the following phases: (1) pre-phase, (2) self-learning-phase, (3) Synchronous online face-to-face phase, (4) transfer-phase, (5) evaluation. Recommendations and potential tools are provided for each phase. The oICM is an innovative and easy to use approach to shape digital teaching and learning processes during and after the CoVid19 pandemic. This blueprint is developed by the committee "Digitalization" of the German Association for Medical Education (GMA) for facilitators without any prior experience with the ICM, but also for those who already teach in a traditional ICM.

Twelve tips for rapidly migrating to online learning during the COVID-19 pandemic

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has resulted in a massive adaptation in health professions education, with a shift from in-person learning activities to a sudden heavy reliance on internet-mediated education. Some health professions schools will have already had considerable educational technology and cultural infrastructure in place, making such a shift more of a different emphasis in provision. For others, this shift will have been a considerable dislocation for both educators and learners in the provision of education. To aid educators make this shift effectively, this 12 Tips article presents a compendium of key principles and practical recommendations that apply to the modalities that make up online learning. The emphasis is on design features that can be rapidly implemented and optimised for the current pandemic. Where applicable, we have pointed out how these short-term shifts can also be beneficial for the long-term integration of educational technology into the organisations' infrastructure. The need for adaptability on the part of educators and learners is an important over-arching theme. By demonstrating these core values of the health professions school in a time of crisis, the manner in which the shift to online learning is carried out sends its own important message to novice health professionals who are in the process of developing their professional identities as learners and as clinicians.

The need for longitudinal clinical reasoning teaching and assessment: Results of an international survey

Background: Clinical reasoning is a key ability essential for practising health professionals. However, little is known about the current global adoption of clinical reasoning teaching and assessment.Purpose: We aimed to provide insights into how clinical reasoning is deliberately taught and assessed in curricula worldwide and to identify needs and perceived barriers for teaching clinical reasoning to students and educators.Methods: A questionnaire was devised by an international expert group and distributed in a large international medical education community. Data were collected in 2018 and analysed using descriptive statistics. We identified themes in free-text responses using content analysis.Results: Three hundred and thirteen responses from 76 countries were collected. Most respondents were from Europe (34%). While the presence of a longitudinal clinical reasoning curriculum was only reported by 28%, 85% stated that such a curriculum was needed. The lack of awareness of the need to explicitly teach clinical reasoning was the most commonly identified barrier. For assessment, the greatest need identified was for more workplace-based assessment.Conclusions: Global respondents indicate the need to implement explicit longitudinal clinical reasoning curricula. Our findings suggest that efforts should be put into improving faculty development, including evidence-based materials on how to teach and assess clinical reasoning.

Learning clinical reasoning: how virtual patient case format and prior knowledge interact

INTRODUCTION

Clinical reasoning has been fostered with varying case formats including the use of virtual patients. Existing literature points to different conclusions regarding which format is most beneficial for learners with diverse levels of prior knowledge. We designed our study to better understand which case format affects clinical reasoning outcomes and cognitive load, dependent on medical students' prior knowledge.

METHODS

Overall, 142 medical students (3 rd to 6 th year) were randomly assigned to either a whole case or serial cue case format. Participants worked on eight virtual patients in their respective case format. Outcomes included diagnostic accuracy, knowledge, and cognitive load.

RESULTS

We found no effect of case format on strategic knowledge scores pre- vs post-test (whole case learning gain = 3, 95% CI. -.01 to .01, serial cue learning gain = 3, 95% CI. -.06 to .00 p = .50). In both case formats, students with high baseline knowledge (determined by median split on the pre-test in conceptual knowledge) benefitted from learning with virtual patients (learning gain in strategic knowledge = 5, 95% CI .03 to .09, p = .01) while students with low prior knowledge did not (learning gain = 0, 95%CI -.02 to .02). We found no difference in diagnostic accuracy between experimental conditions (difference = .44, 95% CI -.96 to .08, p = .22), but diagnostic accuracy was higher for students with high prior knowledge compared to those with low prior knowledge (difference = .8, 95% CI 0.31 to 1.35, p < .01). Students with low prior knowledge experienced higher extraneous cognitive load than students with high prior knowledge (multiple measurements, p < .01).

CONCLUSIONS

The whole case and serial cue case formats alone did not affect students' knowledge gain or diagnostic accuracy. Students with lower knowledge experienced increased cognitive load and appear to have learned less from their interaction with virtual patients. Cognitive load should be taken into account when attempting to help students learn clinical reasoning with virtual patients, especially for students with lower knowledge.

The influence of prompts on final year medical students' learning process and achievement in ECG interpretation

Objective: ECG interpretation is prone to errors that can lead to relevant misdiagnoses and incorrect treatment. Prompts are one way in lectures to encourage learning from one's own mistakes and to reduce error rates. Prompts are measures such as questions, hints, and suggestions of content-related or metacognitive nature, which can lead to self-explanation in the learner and thus to a deeper understanding of an issue. The aim of the study was therefore to investigate whether the use of prompts can reduce the error rate in ECG interpretation among students. Method: In a 2x2 experimental test and control group design, N=100 final year medical students carried out ECG interpretation tasks in the form of online case vignettes in CASUS^®. In these tasks, justification prompts (B) and error analysis prompts (F) were systematically varied in four groups and the learning success was measured using a knowledge test. In addition, prior knowledge in ECG interpretation, motivation, interest in the topic, subjective confidence in ECG interpretation, and cognitive load was collected. Results: Neither error analysis prompts nor justification prompts had a significant effect on the correct ECG interpretation by students, F(1,96)=1.03, p=.31. Justification prompts seemed to have a positive effect on the confidence of answering the questions, F(1,96)=10.15, p=.002, partial η² =.10; and a negative effect on student motivation, F(1,96)=8.13 , p=.005, partial η² =.08; but both with comparable diagnostic accuracy. Conclusion: The present study could not confirm the positive effects of prompts on the error rate in ECG interpretation reported in the literature but showed significant effects on subjective confidence and motivation which should be investigated in further studies.

Blended learning: ten tips on how to implement it into a curriculum in healthcare education

Blended learning is a meaningful combination of online and face-to-face teaching and learning. In this article we summarize relevant aspects of this format and provide ten tips for educators and curriculum developers on implementing a blended learning curriculum in healthcare education. These general tips are derived from our experience and the available literature and cover the planning and implementation process.

Digital teaching as an instrument for cross-location teaching networks in medical informatics: opportunities and challenges

The increasingly digitized healthcare system requires new skills from all those involved. In order to impart these competencies, appropriate courses must be developed at educational institutions. In view of the rapid development of new aspects of digitization, this presents a challenge; suitable teaching formats must be developed successively. The establishment of cross-location teaching networks is one way to better meet training needs and to make the necessary spectrum of educational content available. As part of the Medical Informatics Initiative, the HiGHmed consortium is establishing such a teaching network, in the field of medical informatics, which covers many topics related to the digitization of the health care system. Various problem areas in the German education system were identified that hinder the development of the teaching network. These problem areas were prioritized firstly according to the urgency of the solution from the point of view of the HiGHmed consortium and secondly according to existing competencies in the participating societies. A workshop on the four most relevant topics was organized with experts from the German Society for Medical Informatics, Biometry and Epidemiology (GMDS), the Society for Medical Education (GMA) and the HiGHmed consortium. These are: recognition of exam results from teaching modules that are offered digitally and across locations, and their integration into existing curricula; recognition of digital, cross-location teaching in the teachers' teaching load; nationwide uniform competencies for teachers, in order to be able to conduct digital teaching effectively and with comparable quality; technical infrastructure to efficiently and securely communicate and manage the recognition of exam results between educational institutions. For all subject areas, existing preliminary work was identified on the basis of working questions, and short- and long-term needs for action were formulated. Finally, a need for the redesign of a technologically supported syntactic and semantic interoperability of learning performance recording was identified.

Uncovering the relation between clinical reasoning and diagnostic accuracy - An analysis of learner's clinical reasoning processes in virtual patients

BACKGROUND

Clinical reasoning is an important topic in healthcare training, assessment, and research. Virtual patients (VPs) are a safe environment to teach, assess and perform research on clinical reasoning and diagnostic accuracy. Our aim was to explore the details of the clinical reasoning process and diagnostic accuracy of undergraduate medical students when working with VPs using a concept mapping tool.

METHODS

Over seven months we provided access to 67 German and 30 English VPs combined with a concept mapping tool to visualize and measure the clinical reasoning process of identifying problems, differential diagnoses, recommended tests and treatment options, and composing a summary statement about a VP. A final diagnosis had to be submitted by the learners in order to conclude the VP scenario. Learners were allowed multiple attempts or could request the correct diagnosis from the system.

RESULTS

We analyzed 1,393 completed concept maps from 317 learners. We found significant differences between maps with a correct final diagnosis on one or multiple attempts and maps in which learners gave up and requested the solution from the system. These maps had lower scores, fewer summary statements, and fewer problems, differential diagnoses, tests, and treatments.

CONCLUSIONS

The different use patterns and scores between learners who had the correct final diagnosis on one or multiple attempts and those who gave up, indicate that diagnostic accuracy in the form of a correct final diagnosis on the first attempt has to be reconsidered as a sole indicator for clinical reasoning competency. For the training, assessment, and research of clinical reasoning we suggest focusing more on the details of the process to reach a correct diagnosis, rather than whether it was made in the first attempt.

How to tell a patient's story? Influence of the case narrative design on the clinical reasoning process in virtual patients

BACKGROUND

Virtual patients (VPs) are narrative-based educational activities to train clinical reasoning in a safe environment. Our aim was to explore the influence of the design of the narrative and level of difficulty on the clinical reasoning process, diagnostic accuracy and time-on-task.

METHODS

In a randomized controlled trial, we analyzed the clinical reasoning process of 46 medical students with six VPs in three different variations: (1) patients showing a friendly behavior, (2) patients showing a disruptive behavior and (3) a version without a patient story.

RESULTS

For easy VPs, we did not see a significant difference in diagnostic accuracy. For difficult VPs, the diagnostic accuracy was significantly higher for participants who worked on the friendly VPs compared to the other two groups. Independent from VP difficulty, participants identified significantly more problems and tests for disruptive than for friendly VPs; time on task was comparable for these two groups. The extrinsic motivation of participants working on the VPs without a patient story was significantly lower than for the students working on the friendly VPs.

CONCLUSIONS

Our results indicate that the measured VP difficulty has a higher influence on the clinical reasoning process and diagnostic accuracy than the variations in the narratives.

Advancing clinical reasoning in virtual patients - development and application of a conceptual framework

Background: Clinical reasoning is a complex skill students have to acquire during their education. For educators it is difficult to explain their reasoning to students, because it is partly an automatic and unconscious process. Virtual Patients (VPs) are used to support the acquisition of clinical reasoning skills in healthcare education. However, until now it remains unclear which features or settings of VPs optimally foster clinical reasoning. Therefore, our aims were to identify key concepts of the clinical reasoning process in a qualitative approach and draw conclusions on how each concept can be enhanced to advance the learning of clinical reasoning with virtual patients. Methods: We chose a grounded theory approach to identify key categories and concepts of learning clinical reasoning and develop a framework. Throughout this process, the emerging codes were discussed with a panel of interdisciplinary experts. In a second step we applied the framework to virtual patients. Results: Based on the data we identified the core category as the "multifactorial nature of learning clinical reasoning". This category is reflected in the following five main categories: Psychological Theories, Patient-centeredness, Context, Learner-centeredness, and Teaching/Assessment. Each category encompasses between four and six related concepts. Conclusions: With our approach we were able to elaborate how key categories and concepts of clinical reasoning can be applied to virtual patients. This includes aspects such as allowing learners to access a large number of VPs with adaptable levels of complexity and feedback or emphasizing dual processing, errors, and uncertainty.

A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study

BACKGROUND

Clinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning.

OBJECTIVES

Keeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills.

METHODS

We designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient's illness script as a concept map when they are working on a VP scenario. The student's map is compared with the experts' reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license.

RESULTS

We conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons.

CONCLUSIONS

The presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms.

Do virtual patients prepare medical students for the real world? Development and application of a framework to compare a virtual patient collection with population data

BACKGROUND

An important aspect of virtual patients (VPs), which are interactive computer-based patient scenarios, is authenticity. This includes design aspects, but also how a VP collection represents a patient population and how a patient is presented in a VP scenario. Therefore, our aim was to analyze VP scenarios integrated into the combined internal medicine and surgery curriculum at the University of Munich (LMU) and compare the results with data from the population in Germany.

METHOD

We developed a coding framework with four main categories: patient data, patient representation, diagnoses, and setting. Based on the framework we analyzed 66 VP and compared the results with data from the German healthcare system.

RESULTS

Especially in the categories of patient data and patient representation, the VPs presented an unrealistic image of the real world; topics such as unemployment, disability, or migration background were almost non-existent. The diagnoses of the VPs and the onset of diseases were comparable with the healthcare data.

CONCLUSIONS

An explanation for the lack of representativeness of the patient data and representation might be a trend to create VPs based on fictional patient stories with VP authors trying to minimize complexity and cognitive load for the students. We suggest raising awareness among VP authors concerning personalized representations of patients without overwhelming their students. Our framework can support educators to assess the authenticity and diversity of a VP collection.

The power of the pen: how to make physicians more friendly and patients more attractive

CONTEXT

Studies have shown that patients' subjective perceptions of physicians' competence and friendliness are relevant aspects of a successful treatment, influencing patients' well-being and trust in the physician. Psychological research has repeatedly shown that unconsciously contracting muscles that are usually used to smile can intensify and even elicit positive feelings (known as facial feedback). Empirical evidence also suggests that a smiling person is favourably judged by others with respect to attractiveness and trustworthiness.

AIM

This study's purpose was to investigate how an induced muscle contraction, similar to that of a smile, affects physicians' interactions with a standardised patient. It was expected that the 'smile intervention' would affect physicians' and patients' perceptions, resulting in higher ratings of the friendliness and attractiveness of physicians in the intervention group.

METHODS

Twenty physicians participated in the randomised controlled study (10 male, 10 female). Physicians were randomly assigned to one of two conditions: an intervention group (performing an easy cognitive task while smiling; n = 11) or a control group (performing an easy cognitive task without smiling; n = 9). Afterwards, physicians had a 5-minute consultation with a standardised patient. This consultation was subsequently rated by physicians, the patient and an external rater using 10-point Likert scales.

RESULTS

Physicians in the intervention group were rated as significantly friendlier by the external rater (mean 7.81 versus 7.11; p = 0.097, η²  = 0.15). In addition, physicians in the intervention group rated the patient as significantly more attractive (mean 6.91 versus 4.78; p = 0.017; η²  = 0.28).

CONCLUSIONS

Our results suggest that physicians can influence their friendliness and their perception of patients' attractiveness. Thereby the 'power of pen' can be an efficient method for making the hospital a friendlier place.

A qualitative analysis of virtual patient descriptions in healthcare education based on a systematic literature review

BACKGROUND

Virtual Patients (VPs) have been in the focus of research in healthcare education for many years. The aim of our study was to analyze how virtual patients are described in the healthcare education literature, and how the identified concepts relate to each other.

METHODS

We performed a literature review and extracted 185 descriptions of virtual patients from the articles. In a qualitative content analysis approach we inductively-deductively developed categories and deducted subcategories. We constructed a concept map to illustrate these concepts and their interrelations.

RESULTS

We developed the following five main categories: Patient, Teacher, Virtual Patient, Curriculum, and Learner. The concept map includes these categories and highlights aspects such as the under-valued role of patients in shaping their virtual representation and opposing concepts, such as standardization of learner activity versus learner-centeredness.

CONCLUSIONS

The presented concept map synthesizes VP descriptions and serves as a basis for both, VP use and discussions of research topics related to virtual patients.

An Introduction to the Inverted/Flipped Classroom Model in Education and Advanced Training in Medicine and in the Healthcare Professions

In describing the inverted classroom model (ICM), the following paper is meant to provide an introduction to the subject matter and to serve as a practical guide for those wishing to employ its methods in basic and advanced medical training and education. The ICM is a blended-learning method in which a self-directed learning phase (individual phase) precedes the classroom-instruction phase. During the online phase, factual knowledge is imparted that serves as a basis for the classroom phase. The classroom phase should subsequently be used to assimilate and implement the previously gained knowledge. In contrast, traditional course concepts impart factual knowledge in lectures, for example, or in other face-to-face teaching formats and are followed by the students' self-instruction in order to assimilate this knowledge. The goal of the ICM is the shift from passive learning to accelerated learning in order to foster learning at cognitively demanding levels such as analysis, synthesis and evaluation. The concurrent increase in production and use of screencasts and educational videos, the Open Educational Resources "movement" and the widespread use of Massive Open Online Courses (MOOCS) have contributed to the increased dissemination of the inverted-classroom method. The intention of the present paper is to provide an introduction to the subject matter and simultaneously to offer a short overview of important projects and research results in the field of medical education and other health professions. Furthermore, an outline is given of the advantages and disadvantages of the model as well as its potential benefit to the future of medical education and training.

Virtual patients--what are we talking about? A framework to classify the meanings of the term in healthcare education

BACKGROUND

The term "virtual patients" (VPs) has been used for many years in academic publications, but its meaning varies, leading to confusion. Our aim was to investigate and categorize the use of the term "virtual patient" and then classify its use in healthcare education.

METHODS

A literature review was conducted to determine all articles using the term "virtual patient" in the title or abstract. These articles were categorized into: Education, Clinical Procedures, Clinical Research and E-Health. All educational articles were further classified based on a framework published by Talbot et al. which was further developed using a deductive content analysis approach.

RESULTS

536 articles published between 1991 and December 2013 were included in the study. From these, 330 were categorized as educational. Classifying these showed that 37% articles used VPs in the form of Interactive Patient Scenarios. VPs in form of High Fidelity Software Simulations (19%) and Virtual Standardized Patients (16%) were also frequent. Less frequent were other forms, such as VP Games. Analyzing the literature across time shows an overall trend towards the use of Interactive Patient Scenarios as the predominant form of VPs in healthcare education.

CONCLUSIONS

The main form of educational VPs in the literature are Interactive Patient Scenarios despite rapid technical advances that would support more complex applications. The adapted classification provides a valuable model for VP developers and researchers in healthcare education to more clearly communicate the type of VP they are addressing avoiding misunderstandings.

Development and evaluation of a virtual patient-based exam in occupational medicine

Occupational medicine (OM), especially the ability to recognize potentially workplace-related diseases or accidents, is important for medical students to learn. The assessment in OM at the Ludwig-Maximilians-University is implemented as a paper-based, multiple-choice question exam that does not assess the students’ ability to remember occupational aspects in clinical contexts. Therefore, the aim of this study was to create and evaluate an online exam based on 19 virtual patients to assess the aspects of OM in an interdisciplinary setting. Thirty-nine medical students participated in the exam with an average score of 65%. The score for freetext questions assessing OM aspects was low (39%). The study showed that the implementation of an interdisciplinary VP-based exam is feasible. The integration of such an interdisciplinary exam would be feasible, for example, as an open-book assessment.

Virtual patient repositories--a comparative analysis

Virtual Patients (VPs) are an important component of medical education. One way to reduce the costs for creating VPs is sharing through repositories. We conducted a literature review to identify existing repositories and analyzed the 17 included repositories in regards to the search functions and metadata they provide. Most repositories provided some metadata such as title or description, whereas other data, such as educational objectives, were less frequent. Future research could, in cooperation with the repository provider, investigate user expectations and usage patterns.

What are effects of a spaced activation of virtual patients in a pediatric course?

BACKGROUND

Virtual patients (VPs) have a long tradition in the curriculum of the medical faculty at the Ludwig-Maximilians-University (LMU) Munich. However, the pediatric VPs were not well integrated into the curriculum and hardly used by students.

METHODS

Therefore we created and implemented a self-contained E-learning module based on virtual patients (VPs), which was embedded into the pediatric curriculum.Students taking this course were divided into two groups. For Group A the virtual patients were activated in a timed order ("spaced activation"), whereas Group B could work on all VPs from the beginning.We investigated the performance of these two groups concerning usage pattern including number of sessions and session duration, score on questions integrated into the VP and results of the intermediate exam.

RESULTS

The integration of the VPs into the pediatric course was successful for both groups. The usage pattern for the spaced activation turned out to be more balanced, however we did not find any significant differences in the results of the intermediate exam, the score on questions included in the VPs nor in the time students spent working on the VPs.

CONCLUSIONS

Our study showed that the spaced activation led to a more balanced VP usage pattern with a lower peak of sessions at the end of the course. Further studies will have to investigate whether a spaced activation of VPs leads to favorable long-term learning outcomes.

Learning the facts in medical school is not enough: which factors predict successful application of procedural knowledge in a laboratory setting?

BACKGROUND

Medical knowledge encompasses both conceptual (facts or "what" information) and procedural knowledge ("how" and "why" information). Conceptual knowledge is known to be an essential prerequisite for clinical problem solving. Primarily, medical students learn from textbooks and often struggle with the process of applying their conceptual knowledge to clinical problems. Recent studies address the question of how to foster the acquisition of procedural knowledge and its application in medical education. However, little is known about the factors which predict performance in procedural knowledge tasks. Which additional factors of the learner predict performance in procedural knowledge?

METHODS

Domain specific conceptual knowledge (facts) in clinical nephrology was provided to 80 medical students (3rd to 5th year) using electronic flashcards in a laboratory setting. Learner characteristics were obtained by questionnaires. Procedural knowledge in clinical nephrology was assessed by key feature problems (KFP) and problem solving tasks (PST) reflecting strategic and conditional knowledge, respectively.

RESULTS

Results in procedural knowledge tests (KFP and PST) correlated significantly with each other. In univariate analysis, performance in procedural knowledge (sum of KFP+PST) was significantly correlated with the results in (1) the conceptual knowledge test (CKT), (2) the intended future career as hospital based doctor, (3) the duration of clinical clerkships, and (4) the results in the written German National Medical Examination Part I on preclinical subjects (NME-I). After multiple regression analysis only clinical clerkship experience and NME-I performance remained independent influencing factors.

CONCLUSIONS

Performance in procedural knowledge tests seems independent from the degree of domain specific conceptual knowledge above a certain level. Procedural knowledge may be fostered by clinical experience. More attention should be paid to the interplay of individual clinical clerkship experiences and structured teaching of procedural knowledge and its assessment in medical education curricula.

New approaches to linking clinical guidelines to virtual patients

An often reported challenge of evidence-based medicine concerns increasing use of clinical guidelines in practice. One of the proposed improvements is to promote guidelines by presenting them in conjunction with virtual patients. Three approaches to linking clinical guidelines to virtual patients are presented in this paper: (1) guidelines as a source for generating virtual patients; (2) guidelines hyper-flowchart as a virtual patient progress indicator; (3) guidelines flowchart reconstruction as a learning activity in virtual patient systems. The scenarios have been preliminarily evaluated using two demonstrator applications: Bit Pathways and CASUS. Challenges and direction for further development are proposed.

Criteria to assess the quality of virtual patients

Quality assessment of virtual patients (VP) is important but still insufficiently standardized. We developed categories and criteria to assess the quality of virtual patients. These categories reflect the life cycle of a VP from the planning to the development, implementation and evaluation. Such elaborated criteria will help authors to create VPs and curriculum planners to assess the quality of implemented VPs and choose high quality VPs from repositories.

Using electronic flashcards to promote learning in medical students: retesting versus restudying

CONTEXT

The superiority of retesting over restudying in terms of knowledge retention and skills acquisition has been proven in both laboratory and classroom settings, as well as in doctors' practice. However, it is still unclear how important retesting strategies are to the learning of relevant factual knowledge in undergraduate medical education.

METHODS

Eighty students in Years 3-5 of medical school in Munich participated in a prospective, randomised, double-blinded, controlled study in which they were exposed to 30 electronic flashcards designed to help them memorise key factual knowledge in the domain of clinical nephrology. The flashcards were presented in four successive learning cycles, each consisting of a study period and a subsequent test period. Half of all participants were randomised to repetitive studying (restudy group) and half were randomised to repetitive testing (retest group) of successfully memorised flashcards. Knowledge retention was assessed after 1 week and 6 months. Additionally, personal data, self-reflection on the efficacy of the learning strategies and judgements of learning were obtained by questionnaires.

RESULTS

Repetitive testing promoted better recall than repetitive studying after 1 week (p<0.001). However, after 6 months general recall was poor and no difference between the restudy and retest groups was observed. Time on task and number of trials, in addition to sex, age, performance and psycho-social background, did not vary between the groups. Self-predictions of student performance did not correlate with actual performance.

CONCLUSIONS

In the context of using electronic flashcards, repetitive testing is a more potent learning strategy than repetitive studying for short-term but not long-term knowledge retention in clinical medical students. Although students use testing as a learning strategy, they seem to be unaware of its superiority in supporting short-term knowledge retention.

Implementation of virtual patients in the training for occupational health in Latin America

Health professionals trained in occupational health are essential to reduce the burden of occupational accidents and diseases. However, training resources are limited globally. We aimed to promote occupational health and safety (OHS) using virtual patients (VPs) in Brazil, Chile, and Germany. Virtual patients were created in three Latin-American health centers. So-called "partner VPs" comparing the distinct health care systems were designed. Translation, adaptation to different medical and legal systems, expert review, implementation into under- and postgraduate teaching, and user evaluation were performed. Twelve VPs covering traditional and contemporary OHS issues are available in Spanish, Portuguese, and English. Overall, 2371 students used the VPs. The number of Latin American users who evaluated VP content and relevance for their professional career was statistically significantly higher than the number of German students. VPs are a feasible learning method for OHS in middle-income countries. Partner VPs seem to be useful for teaching global aspects.

Push and pull models to manage patient consent and licensing of multimedia resources in digital repositories for case-based reasoning

Patient consents for distribution of multimedia constitute a significant element of medical case-based repositories in medicine. A technical challenge is posed by the right of patients to withdraw permission to disseminate their images or videos. A technical mechanism for spreading information about changes in multimedia usage licenses is sought. The authors gained their experience by developing and managing a large (&gt;340 cases) repository of virtual patients within the European project eViP. The solution for dissemination of license status should reuse and extend existing metadata standards in medical education. Two methods: PUSH and PULL are described differing in the moment of update and the division of responsibilities between parties in the learning object exchange process. The authors recommend usage of the PUSH scenario because it is better adapted to legal requirements in many countries. It needs to be stressed that the solution is based on mutual trust of the exchange partners and therefore is most appropriate for use in educational alliances and consortia. It is hoped that the proposed models for exchanging consents and licensing information will become a crucial part of the technical frameworks for building case-based repositories.

Developing and analysing a curriculum map in Occupational- and Environmental Medicine

BACKGROUND

During the last 5 years a fundamental curriculum reform was realized at the medical school of the Ludwig-Maximilians-University. In contrast to those efforts, the learning objectives were not defined consistently for the curriculum and important questions concerning the curriculum could not be answered. This also applied to Occupational and Environmental Medicine where teachers of both courses were faced with additional problems such as the low number of students attending the lectures.The aims of the study were to develop and analyse a curriculum map for Occupational and Environmental Medicine based on learning objectives using a web-based database.Furthermore we aimed to evaluate student perception about the curricular structure.

METHODS

Using a web-based learning objectives database, a curriculum map for Occupational and Environmental Medicine was developed and analysed. Additionally online evaluations of students for each course were conducted.

RESULTS

The results show a discrepancy between the taught and the assessed curriculum. For both curricula, we identified that several learning objectives were not covered in the curriculum. There were overlaps with other content domains and redundancies within both curricula. 53% of the students in Occupational Medicine and 43% in Environmental Medicine stated that there is a lack of information regarding the learning objectives of the curriculum.

CONCLUSIONS

The results of the curriculum mapping and the poor evaluation results for the courses suggest a need for re-structuring both curricula.

Web-based collaborative training of clinical reasoning: a randomized trial

BACKGROUND

Clinical reasoning skills are essential for medical practice. Problem-based collaborative learning via the internet might prove useful in imparting these skills.

AIM

This randomized study assessed whether web-based learning (WBL) is superior to face-to-face problem-based learning (PBL) in the setting of a 6-week cardio-respiratory course.

METHODS

During winter term 2007/08, all 148 fourth-year medical students enrolled in the 6-week course consented to be randomized in small groups to diagnose a patient complaining of dyspnoea either using a virtual collaborative online module or a traditional PBL session. Clinical reasoning skills were assessed by means of a key feature examination at the end of the course.

RESULTS

No significant difference between the mean scores of both study groups was detected (p = 0.843). In virtual learning groups, costs for diagnostic tests were significantly correlated to the number of contributions to online group discussions (r = 0.881; p = 0.002). Evaluation data favored traditional PBL sessions over virtual collaborative learning.

CONCLUSION

While virtual collaborative learning was as effective as traditional PBL regarding the acquisition of clinical reasoning skills, it was less well accepted than traditional PBL. Future research needs to determine the ideal format and time-point for computer-assisted learning in medical education.

[Virtual patients in medical education: a comparison of various strategies for curricular integration]

INTRODUCTION

E-Learning applications are an integral part of modern medical curricula. Nevertheless, there is only a narrow empirical basis for an optimal integration strategy of computerized teaching methods in medical education. This article focuses on the integration experiences with three different online systems for interactive virtual patients (VPs) in clinical undergraduate medical education at the universities of Heidelberg, Munich (LMU), and Wuerzburg.

METHODS

Five different integration strategies for VPs are presented and compared with respect to motivational aspects, logistics and acceptance of both students and teachers.

RESULTS

A voluntary use of VPs without curricular integration leads to low acceptance. Exam relevance of VPs and integration with face-to-face teaching are key factors for a high level of acceptance. The assets and drawbacks of all described strategies are discussed in the conclusions of this article.

CONCLUSIONS

Case-based e-learning can be successfully integrated into clinical undergraduate medical education when key factors are considered.

Development and validation of strategies to test for interoperability of virtual patients

Interoperability of e-learning resources requires the adherence to specific standards. In the domain of virtual patients (VP) a central role is played by the MedBiquitous' MVP specification and its application profile proposed by the eViP (Electronic Virtual Patients) project. An important factor in promoting a standard is the use of metrics for assessing the conformity of the resources to the constraints imposed by the specifications. The overall aim of this study was to explore strategies to test for conformance and investigate the capabilities and limitations of automated conformance testing. A four-level scale of conformance of virtual patient packages to the eViP profile is presented, as well as two implementations of conformance testing applications. The developed tools have been tested upon level two on a sample of four VP cases acquired from the eViP repository of virtual patients.

Enabling interoperability, accessibility and reusability of virtual patients across Europe - design and implementation

Virtual Patients (VPs) have successfully been integrated into medical and healthcare curricula for a number of years. Lack of time and resources is a frequently reported problem encountered when developing VPs for teaching and learning. Consequently there is a need for cross-institutional repositories of VPs. The aims of the study were two-fold: to enable interoperability between virtual patient systems and to investigate if (and how) an application profile is implemented in four different types of VP systems. This European collaborative implementation of a blend of several specifications (Medbiquitous VP XML, Medbiquitous Healthcare LOM, and SCORM) is innovative and the study has shown a variation in how the application profile could be implemented.