A randomized controlled trial

BACKGROUND

History taking and clinical reasoning are important skills that require knowledge, cognition and meta-cognition. It is important that a trainee must experience multiple encounters with different patients to practice these skills. However, patient safety is also important, and trainees are not allowed to handle critically ill patients. To address this issue, a randomized controlled trial was conducted to determine the effectiveness of using Virtual Patients (VP) versus Standardized Patients (SP) in acquiring clinical reasoning skills in ophthalmology postgraduate residents.

METHODS

Postgraduate residents from two hospitals in Lahore, Pakistan, were randomized to either the VP group or the SP group and were exposed to clinical reasoning exercise via the VP or SP for 30 min after the pretest. This was followed by a posttest. One month after this activity, a follow-up posttest was conducted. The data were collected and analysed using IBM-SPSS version 25. Repeated measures ANOVA was used to track the effect of learning skills over time.

RESULTS

The mean age of the residents was 28.5 ± 3 years. The male to female ratio was 1:1.1. For the SP group, the mean scores were 12.6 ± 3.08, 16.39 ± 3.01 and 15.39 ± 2.95, and for the VP group, the mean scores were 12.7 ± 3.84, 16.30 ± 3.19 and 15.65 ± 3.18 for the pretest, posttest and follow-up posttest, respectively (p value < 0.00). However, the difference between the VP and SP groups was not statistically significant (p = 0.896). Moreover, there was no statistically significant difference between the VP and SP groups regarding the retention of clinical reasoning ability. In terms of learning gain, compared with the VP group, the SP group had a score of 51.46% immediately after clinical reasoning exercise as compared to VP group, in which it was 49.1%. After one month, it was 38.01 in SP and 40.12% in VP group.

CONCLUSION

VPs can be used for learning clinical reasoning skills in postgraduate ophthalmology residents in a safe environment. These devices can be used repeatedly without any risk to the real patient. Although similarly useful, SP is limited by its nonavailability for repeated exercises.

Clinical virtual simulation: predictors of user acceptance in nursing education

BACKGROUND

Using virtual patients integrated in simulators expands students' training opportunities in healthcare. However, little is known about the usability perceived by students and the factors/determinants that predict the acceptance and use of clinical virtual simulation in nursing education.

OBJECTIVES

To identify the factors/determinants that predict the acceptance and use of clinical virtual simulation in learning in nursing education.

METHODS

Observational, cross-sectional, analytical study of the use of clinical virtual simulation in nursing to answer the research question: What factors/determinants predict the acceptance and use of a clinical virtual simulator in nursing education? We used a non-probabilistic sampling, more specifically a convenience sample of nursing degree students. The data were collected through a questionnaire adapted from the Technology Acceptance Model 3. In technology and education, the Technology Acceptance Model is a theoretical model that predicts the acceptance of the use of technology by users.

RESULTS

The sample comprised 619 nursing students, who revealed mean values of perceived usefulness (M = 5.34; SD = 1.19), ease of use (M = 4.74; SD = 1.07), and intention to use the CVS (M = 5.21; SD = 1.18), in a Likert scale of seven points (1-the worst and 7 the best possible opinion). This study validated the use of Technology Acceptance Model 3 adapted and tested the related hypotheses, showing that the model explains 62% of perceived utility, 32% of ease of use, and 54% of intention to use the clinical virtual simulation in nursing by nursing students. The adequacy of the model was tested by analysis of the direct effects of the relationships between the internal constructs (PU-BI, β = 0.11, p = 0.012; PEOU-BI, β = -0.11, p = 0.002) and the direct relations between some of the constructs internal to the Technology Acceptance Model 3 and the external determinants Relevance for learning and Enjoyability. In the proposed model, the external constructs that best predicted perceived usefulness, ease of use, and behaviour intention to use the clinical virtual simulation in nursing were Relevance for learning and Enjoyability.

CONCLUSIONS

These study results allowed us to identify relevance for learning and enjoyability as the main factors/determinants that predict the acceptance and use of clinical virtual simulation in learning in nursing.

Virtual patients in undergraduate psychiatry education: a systematic review and synthesis

Virtual patients are increasingly used in undergraduate psychiatry education. This article reports on a systematic review aimed at providing an overview of different approaches in this context, describing their effectiveness, and thematically comparing learning outcomes across different undergraduate programs. The authors searched PubMed, PsycInfo, CINAHL, and Scopus databases for articles published between 2000 and January 2021. Quantitative and qualitative studies that reported on outcomes related to learners' knowledge, skills, and attitudes following an intervention with virtual patients in undergraduate psychiatry education were reviewed. Outcomes were thematically compared, and a narrative synthesis of the different outcomes and effectiveness was provided. Of 7856 records identified, 240 articles were retrieved for full-text review and 46 articles met all inclusion criteria. There were four broad types of virtual patient interventions: case-based presentation (n = 17), interactive virtual patient scenarios (n = 14), standardized virtual patients (n = 10), and virtual patient videogames (n = 5). The thematic analysis revealed that virtual patients in psychiatry education have been used for learners to construe knowledge about symptomatology and psychopathology, develop interpersonal and clinical communicative skills, and to increase self-efficacy and decrease stigmatizing attitudes towards psychiatric patients. In comparison with no intervention, traditional teaching, and text-based interventions, virtual patients were associated with higher learning outcomes. However, the results did not indicate any superiority of virtual patients over non-technological simulation. Virtual patients in psychiatry education offer opportunities for students from different health disciplines to build knowledge, practice skills, and improve their attitudes towards individuals with mental illness. The article discusses methodological shortcomings in the reviewed literature. Future interventions should consider the mediating effects of the quality of the learning environment, psychological safety, and level of authenticity of the simulation.

"It kinda helped us to be there": students' perspectives on the use of virtual patient software in psychiatry posting

BACKGROUND

At the Faculty of Medicine of the National University of Malaysia, a virtual patient software program, DxR Clinician, was utilised for the teaching of neurocognitive disorder topics during the psychiatry posting of undergraduate medical students in a modified team-based learning (TBL) module. This study aimed to explore medical students' learning experiences with virtual patient.

METHODS

Ten students who previously underwent the learning module were recruited through purposive sampling. The inclusion criteria were: (a) Fourth-year medical students; and (b) Completed psychiatry posting with the new module. Students who dropped out or were unable to participate in data collection were excluded. Two online focus group discussions (FGDs) with five participants each were conducted by an independent facilitator, guided by a questioning route. The data were transcribed verbatim and coded using the thematic analysis approach to identify themes.

RESULTS

Three main themes of their learning experience were identified: (1) fulfilment of the desired pedagogy (2), realism of the clinical case, and (3) ease of use related to technical settings. The pedagogy theme was further divided into the following subthemes: level of entry for students, flexibility of presentation of content, provision of learning guidance, collaboration with peers, provision of feedback, and assessment of performance. The realism theme had two subthemes: how much the virtual patient experience mimicked an actual patient and how much the case scenario reflected real conditions in the Malaysian context. The technical setting theme entailed two subthemes: access to the software and appearance of the user interface. The study findings are considered in the light of learning formats, pedagogical and learning theories, and technological frameworks.

CONCLUSIONS

The findings shed light on both positive and negative aspects of using virtual patients for medical students' psychiatry posting, which opens room for further improvement of their usage in undergraduate psychiatry education.

Diagnosing virtual patients: the interplay between knowledge and diagnostic activities

Clinical reasoning theories agree that knowledge and the diagnostic process are associated with diagnostic success. However, the exact contributions of these components of clinical reasoning to diagnostic success remain unclear. This is particularly the case when operationalizing the diagnostic process with diagnostic activities (i.e., teachable practices that generate knowledge). Therefore, we conducted a study investigating to what extent knowledge and diagnostic activities uniquely explain variance in diagnostic success with virtual patients among medical students. The sample consisted of N = 106 medical students in their third to fifth year of university studies in Germany (6-years curriculum). Participants completed professional knowledge tests before diagnosing virtual patients. Diagnostic success with the virtual patients was assessed with diagnostic accuracy as well as a comprehensive diagnostic score to answer the call for more extensive measurement of clinical reasoning outcomes. The three diagnostic activities hypothesis generation, evidence generation, and evidence evaluation were tracked. Professional knowledge predicted performance in terms of the comprehensive diagnostic score and displayed a small association with diagnostic accuracy. Diagnostic activities predicted comprehensive diagnostic score and diagnostic accuracy. Hierarchical regressions showed that the diagnostic activities made a unique contribution to diagnostic success, even when knowledge was taken into account. Our results support the argument that the diagnostic process is more than an embodiment of knowledge and explains variance in diagnostic success over and above knowledge. We discuss possible mechanisms explaining this finding.

Socioeconomic Level and the Relationship in Glycemic Behavior in the Mexican Population. A Nutritional Alternative Focused on Vulnerable Populations

In this study, numerical approximations were generated to analyze the behavior of glycemic variations in the non-diabetic population of the Mexican republic. The main objective of this work is to obtain an overview of the glycemic variations in the non-diabetic population from different socioeconomic statuses in Mexico (Medium-high, medium, and low). Thus, evaluating the effect on the glucose level under a healthy diet considering the socioeconomic capabilities of the population. Through the national health and nutrition survey of Mexico 2020 and the Mexican food base, 1420 virtual patients were proposed (522 low status, 485 medium status and 413 Medium-High status) focused on simulating the glycemic behavior in each of the survey participants. Considering that the average food expenditure of the Mexican population is $107.00 MXN, and the cost of a healthy diet is $66.50 MXN, the economic sustainability of the Mexican population to adopt a healthy diet is revealed. The particularity of this work is focused on obtaining diverse data that are difficult to access in the development of population analyses. Such is the case of the approach proposed for different socioeconomic statuses. In this way, the proposed methodology provides a framework for complementary research contributions to the subject.

Twine virtual patient games as an online resource for undergraduate diabetes acute care education

BACKGROUND

Virtual patients provide a safe way to simulate authentic clinical practice. Twine is an open-source software that can be used to create intricate virtual patient games, including elements like non-linear free text history taking and time-related changes to the game's narrative. We evaluated the incorporation of Twine virtual patient games into a diabetes acute care online learning package for undergraduate medical students at the University of Glassgow, Scotland.

METHODS

Three games were developed using Twine, Wacom Intuous Pro, Autodesk SketchBook, Camtasia Studio, and simulated patients. Online material included three VP games, eight microlectures, and a single best answer multiple choice question quiz. The games were evaluated at Kirkpatrick Level 1 with an acceptability and usability questionnaire. The entire online package was evaluated at Kirkpatrick Level 2 with pre- and post-course multiple choice and confidence questions, with statistical analysis performed using paired t-tests.

RESULTS

122 of approximately 270 eligible students provided information on resource utilisation, with 96% of these students using at least one online resource. 68% of students who returned surveys used at least one VP game. 73 students provided feedback on the VP games they had played, with the majority of median responses being "agree" on positive usability and acceptability statements. The online resources were associated with a mean multiple choice score increase from 4.37 out of 10 to 7.96 out of 10 (p < 0.0001, 95% CI + 2.99 to + 4.20, n = 52) and a mean total confidence score increase from 4.86 out of 10 to 6.70 out of 10 (p < 0.0001, 95% CI + 1.37 to + 2.30, n = 48).

CONCLUSIONS

Our VP games were well-received by students and promoted engagement with online material. The package of online material led to statistically significant increases in confidence and knowledge in diabetes acute care outcomes. A blueprint with supporting instructions has now been created to facilitate rapid creation of further games using Twine software.

In Silico Evaluation of the Medtronic 780G System While Using the GS3 and Its Calibration-Free Successor, the G4S Sensor

In silico simulation studies using 5807 virtual patients with insulin dependent diabetes have been conducted to estimate the risk and efficacy with the closed-loop 780G pump when switching between Medtronic Guardian Sensor 3 (GS3) and Medtronic Guardian 4 Sensor (G4S), next generation calibration free glucose sensor. To demonstrate by utilizing a case study that captures the merits of in silico studies with single hormone insulin dependent virtual patients that include variability in pharmacokinetics/pharmacodynamics, age, gender, insulin sensitivity and BMIs. Also, to show that in silico studies can uniquely isolate the effect of a single variable on clinical outcomes. Simulation studies results were compared to clinical and commercial data and were separated by age groups and pump settings. The commercial data, the clinical study data and the simulation studies predicted that switching between GS3 to G4S will introduce a change in glucose average, percentage time between 70 and 180 mg/dL, and percentage time below 70 mg/dL of: 5.2, 3.4, and 3.1 mg/dL, - 1.1, 0.2, and - 1.1%, and - 0.6, - 1.0, and - 0.3%, respectively. We demonstrated that our simulation studies were able to predict the difference in glycemic outcomes when switching between different sensors in real world setting, better than a small clinical controlled study. As predicted, switching between GS3 and G4S sensors with the 780G system does not introduce clinical risk and maintain the clinical outcomes of the sensor. We demonstrated the ability of insulin dependent diabetes virtual patients to predict clinical outcomes and to augment or even replace some small clinical studies.

Sensitivity Analysis of a Mathematical Model Simulating the Post-Hepatectomy Hemodynamics Response

Recently a lumped-parameter model of the cardiovascular system was proposed to simulate the hemodynamics response to partial hepatectomy and evaluate the risk of portal hypertension (PHT) due to this surgery. Model parameters are tuned based on each patient data. This work focuses on a global sensitivity analysis (SA) study of such model to better understand the main drivers of the clinical outputs of interest. The analysis suggests which parameters should be considered patient-specific and which can be assumed constant without losing in accuracy in the predictions. While performing the SA, model outputs need to be constrained to physiological ranges. An innovative approach exploits the features of the polynomial chaos expansion method to reduce the overall computational cost. The computed results give new insights on how to improve the calibration of some model parameters. Moreover the final parameter distributions enable the creation of a virtual population available for future works. Although this work is focused on partial hepatectomy, the pipeline can be applied to other cardiovascular hemodynamics models to gain insights for patient-specific parameterization and to define a physiologically relevant virtual population.

A simulator with realistic and challenging scenarios for virtual T1D patients undergoing CSII and MDI therapy

In silico simulations have become essential for the development of diabetes treatments. However, currently available simulators are not challenging enough and often suffer from limitations in insulin and meal absorption variability, which is unable to realistically reflect the dynamics of people with type 1 diabetes (T1D). Additionally, T1D simulators are mainly designed for the testing of continuous subcutaneous insulin infusion (CSII) therapies. In this work, a simulator is presented that includes a generated virtual patient (VP) cohort and both fast- and long-acting Glargine-100 U/ml (Gla-100), Glargine-300 U/ml (Gla-300), and Degludec-100 U/ml (Deg-100) insulin models. Therefore, in addition to CSII therapies, multiple daily injections (MDI) therapies can also be tested. The Hovorka model and its published parameter probability distributions were used to generate cohorts of VPs that represent a T1D population. Valid patients are filtered through restrictions that guarantee that they are physiologically acceptable. To obtain more realistic scenarios, basal insulin profile patterns from the literature have been used to identify variability in insulin sensitivity. A library of mixed meals identified from real data has also been included. This work presents and validates a methodology for the creation of realistic VP cohorts that include physiological variability and a simulator that includes challenging and realistic scenarios for in silico testing. A cohort of 47 VPs has been generated and in silico simulations of both CSII and MDI therapies were performed in open-loop. The simulation outcome metrics were contrasted with literature results.

Understanding virtual patients efficiently and rigorously by combining machine learning with dynamical modelling

Individual biological organisms are characterized by daunting heterogeneity, which precludes describing or understanding populations of ‘patients’ with a single mathematical model. Recently, the field of quantitative systems pharmacology (QSP) has adopted the notion of virtual patients (VPs) to cope with this challenge. A typical population of VPs represents the behavior of a heterogeneous patient population with a distribution of parameter values over a mathematical model of fixed structure. Though this notion of VPs is a powerful tool to describe patients’ heterogeneity, the analysis and understanding of these VPs present new challenges to systems pharmacologists. Here, using a model of the hypothalamic–pituitary–adrenal axis, we show that an integrated pipeline that combines machine learning (ML) and bifurcation analysis can be used to effectively and efficiently analyse the behaviors observed in populations of VPs. Compared with local sensitivity analyses, ML allows us to capture and analyse the contributions of simultaneous changes of multiple model parameters. Following up with bifurcation analysis, we are able to provide rigorous mechanistic insight regarding the influences of ML-identified parameters on the dynamical system’s behaviors. In this work, we illustrate the utility of this pipeline and suggest that its wider adoption will facilitate the use of VPs in the practice of systems pharmacology.

Machine learning for detection of stenoses and aneurysms: application in a physiologically realistic virtual patient database

This study presents an application of machine learning (ML) methods for detecting the presence of stenoses and aneurysms in the human arterial system. Four major forms of arterial disease-carotid artery stenosis (CAS), subclavian artery stenosis (SAS), peripheral arterial disease (PAD), and abdominal aortic aneurysms (AAA)-are considered. The ML methods are trained and tested on a physiologically realistic virtual patient database (VPD) containing 28,868 healthy subjects, adapted from the authors previous work and augmented to include disease. It is found that the tree-based methods of Random Forest and Gradient Boosting outperform other approaches. The performance of ML methods is quantified through the [Formula: see text] score and computation of sensitivities and specificities. When using six haemodynamic measurements (pressure in the common carotid, brachial, and radial arteries; and flow-rate in the common carotid, brachial, and femoral arteries), it is found that maximum [Formula: see text] scores larger than 0.9 are achieved for CAS and PAD, larger than 0.85 for SAS, and larger than 0.98 for both low- and high-severity AAAs. Corresponding sensitivities and specificities are larger than 90% for CAS and PAD, larger than 85% for SAS, and larger than 98% for both low- and high-severity AAAs. When reducing the number of measurements, performance is degraded by less than 5% when three measurements are used, and less than 10% when only two measurements are used for classification. For AAA, it is shown that [Formula: see text] scores larger than 0.85 and corresponding sensitivities and specificities larger than 85% are achievable when using only a single measurement. The results are encouraging to pursue AAA monitoring and screening through wearable devices which can reliably measure pressure or flow-rates.

Influence of patient immigrant status on physician trainee diabetes treatment decisions: a virtual patient experimental study

To determine the effect of patient immigrant status on physician trainees' diabetes treatment decisions. Participants were 140 physician trainees ('providers'). Providers viewed videos and vignettes of virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group and individual levels. Providers were less likely to refer foreign-born (vs. U.S.-born) patients to endocrinology. Individual-level results showed an almost even split between treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add oral hypoglycemic agent, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). Physician trainees are less likely to refer foreign-born patients to endocrinology. Half of individual-level decisions were influenced by patient immigrant status, but group-level analyses mask these differences. Systematic treatment differences based on non-relevant factors could lead to adverse outcomes for immigrants.

Connecting a simulated virtual patient program with experiential practicums: Perspectives from year three students

BACKGROUND AND PURPOSE

Research indicates that the simulated learning tools known as virtual patients (VPs) are valued by pharmacy students and impact students' knowledge and confidence. However, research is needed to understand how students can be supported to make intended connections between VP cases and real-life clinical scenarios. The purpose of this study was to examine whether and how VP cases influence students' clinical reasoning skills, confidence, thought processes, and preparedness for their experiential practicums.

EDUCATIONAL ACTIVITY AND SETTING

Third-year entry-to-practice doctor of pharmacy students who had completed at least one VP case in second year prior to their experiential practicums were surveyed in fall 2018 after having completed their experiential practicums. Surveys were structured to solicit student perceptions related to how students bridged VP cases and real-life clinical scenarios and were analyzed using a mixed-methods design.

FINDINGS

Forty-three students completed the survey. Students perceived that VP cases most significantly impacted their clinical reasoning skills due to the opportunity cases afforded them to explore patient data and navigate relevant information. The largest limitation of VP cases to students' learning was that the cases differed from their experiences. Students' suggestions included opportunities for more practice using VP cases and an expanded repertoire of medical conditions offered through case exposure.

SUMMARY

More research is needed to understand how to help students connect VP cases to their experiential practicums to make them more effective learning tools.

A mechanistic systems pharmacology modeling platform to investigate the effect of PD-L1 expression heterogeneity and dynamics on the efficacy of PD-1 and PD-L1 blocking antibodies in cancer

Tumors have developed multitude of ways to evade immune response and suppress cytotoxic T cells. Programed cell death protein 1 (PD-1) and programed cell death ligand 1 (PD-L1) are immune checkpoints that when activated, rapidly inactivate the cytolytic activity of T cells. Expression heterogeneity of PD-L1 and the surface receptor dynamics of both PD-1 and PD-L1 may be important parameters in modulating the immune response. PD-L1 is expressed on both tumor and non-tumor immune cells and this differential expression reflects different aspects of anti-tumor immunity. Here, we developed a mechanistic computational model to investigate the role of PD-1 and PD-L1 dynamics in modulating the efficacy of PD-1 and PD-L1 blocking antibodies. Our model incorporates immunological synapse restricted interaction of PD-1 and PD-L1, basal parameters for receptor dynamics, and T cell interaction with tumor and non-tumor immune cells. Simulations predict the existence of a threshold in PD-1 expression above which there is no efficacy for both anti-PD-1 and anti-PD-L1. Model also predicts that anti-tumor response is more sensitive to PD-L1 expression on non-tumor immune cells than tumor cells. New combination strategies are suggested that may enhance efficacy in resistant cases such as combining anti-PD-1 with a low dose of anti-PD-L1 or with inhibitors of PD-L1 recycling and synthesis. Another combination strategy suggested by the model is the combination of anti-PD-1 and anti-PD-L1 with enhancers of PD-L1 degradation rate. Virtual patients are then generated to test specific biomarkers of response. Intriguing predictions that emerge from the virtual patient simulations are that PD-1 blocking antibody results in higher response rate than PD-L1 blockade and that PD-L1 expression density on non-tumor immune cells rather than tumor cells is a predictor of response.

[Blended Learning With Virtual Pediatric Emergency Patients for Medical Students]

Blended Learning With Virtual Pediatric Emergency Patients for Medical Students Abstract. Treating critically ill children is a major challenge for learners. Medical Students often feel inadequately prepared for their later role as physicians. This article describes the implementation and evaluation of blended learning using virtual patients (VP) during the student rotation at the pediatric emergency department Inselspital Bern. Students rated the project as highly beneficial and recommended its integration into the entire clinical curriculum.

Prediction of lung mechanics throughout recruitment maneuvers in pressure-controlled ventilation

Mechanical ventilation (MV) is a core therapy in the intensive care unit (ICU). Some patients rely on MV to support breathing. However, it is a difficult therapy to optimise, where inter- and intra- patient variability leads to significantly increased risk of lung damage. Excessive volume and/or pressure can cause volutrauma or barotrauma, resulting in increased length of time on ventilation, length of stay, cost and mortality. Virtual patient modelling has changed care in other areas of ICU medicine, enabling more personalized and optimal care, and have emerged for volume-controlled MV. This research extends this MV virtual patient model into the increasingly more commonly used pressure-controlled MV mode. The simulation methods are extended to use pressure, instead of both volume and flow, as the known input, increasing the output variables to be predicted (flow and its integral, volume). The model and methods are validated using data from N = 14 pressure-control ventilated patients during recruitment maneuvers, with n = 558 prediction tests over changes of PEEP ranging from 2 to 16 cmH₂O. Prediction errors for peak inspiratory volume for an increase of 16 cmH₂O were 80 [30 - 140] mL (15.9 [8.4 - 31.0]%), with RMS fitting errors of 0.05 [0.03 - 0.12] L. These results show very good prediction accuracy able to guide personalised MV care.

Using Video and Virtual Patients in Problem-Based Learning: a Scoping Review

Problem presentation in problem-based learning can include the use of videos and interactive virtual patients. This review scopes the literature for this variation and what benefits or pitfalls there may be to their use. Themes indicate that videos and virtual patients may better prepare students for future difficult clinical interactions, while also increasing authenticity and memorability of cases. Findings are more inconsistent in determining whether they lead to clear knowledge or critical thinking gains. Despite inconsistent data, in an age where the use of technology is inevitable, the findings of this scoping review can inform future practice and guide innovation.

Using interviews and observations in clinical practice to enhance authenticity in virtual patients for interprofessional education

BACKGROUND

Interprofessional collaboration is increasingly important in healthcare, but interprofessional education (IPE) faces challenges, such as different study programmes with varied schedules and campuses. These challenges can be met, in part, by using web-based virtual patients (VPs) as a tool in IPE. However, demands for relevant patient presentations and clinical practice increase when VPs are used by students from different programmes. The aim of this study was to improve the presentation of professional perspectives regarding nurses and physicians and their collaboration in order to increase the clinical authenticity of existing VPs.

METHODS

Clinical observations were conducted to gain familiarity with the context. Semi-structured interviews were performed with individual nurses and physicians with experience of patients with leg ulcers. The interviews were recorded, transcribed and analysed using thematic analysis.

RESULTS

The clinical observations exposed a lack of interprofessional collaboration in practice with regard to patients with leg ulcers. The interview analysis resulted in two themes: Clinical care and Organizational structure. The theme Clinical care included nursing with a holistic approach to the patient and awareness of the patient's well-being, including nutrition and home situation. The theme Organizational structure revealed a lack of teamwork in primary care. The interviewees stressed learning together and sharing responsibility, and they emphasised the importance of implementing interprofessional learning in the education of nurses and physicians in order to stimulate future teamwork. The VP should offer a broad medical history so that healthcare students are made aware of how a disease can affect the patient's social situation, and thereby illustrate the importance of interprofessional collaboration. The information should also be comprehensive and clear, leading to a diagnosis, so the student can gain clinical knowledge and build a foundation for discussion of treatment.

CONCLUSIONS

Interviews and observations in clinical practice can be used to enhance authenticity in VPs for interprofessional learning. A thorough look at authentic clinical environments can enrich and improve educational settings using VPs, and it can highlight the challenges students can encounter in clinical care of the patient and in an organisation with regard to interprofessional collaboration.

Communication skills training using virtual reality: A descriptive qualitative study

BACKGROUND

Modern medical pedagogical strategies are shifting toward the use of virtual patient simulations.

OBJECTIVE

This study aims to examine students' users' attitudes and experiences and clinical facilitators' perspectives on student performances in the clinical setting post-virtual patient training.

DESIGN

A descriptive qualitative study design was used.

SETTING

Nursing faculty at a local university in Singapore.

PARTICIPANTS

24 nursing undergraduates and six clinical facilitators.

METHODS

This study is a follow-up of an experimental study on the Virtual Counseling Application Using Artificial Intelligence (VCAAI). The study took place from the academic year 2017/2018 ended in November 2019. Focus group discussions and individual interviews were conducted. All interviews and focus group discussions were audiotaped, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Two overarching themes (students' virtual patient user experience and clinical facilitators' evaluations of students' clinical communication skills) comprising six themes were generated. Themes under students' user experience included: 1) attitudes toward virtual patient training, 2) virtual patient's role in student development, and 3) enhanced features and implementation suggestions. Themes under clinical facilitators' evaluations included: 1) insights on students' communication skills and 2) approaches to improve communication skills. An overlapping theme titled 'value of technology in teaching communication' comprised of mutual feedback from both students and clinical facilitators. Early implementation, continued accessibility, enhancing realism and technological improvements to the VCAAI were listed as key areas for program improvement, while increased situational sensitivity and language training are recommended to further enhance students' communication skills.

CONCLUSION

The mixed attitudes toward virtual patient interactions and recognitions of the benefits of virtual patient simulations suggest the potential effectiveness of the use of virtual patients in teaching effective nursing communication skills. However, the lack of authenticity and other limitations need to be addressed before official implementations of such trainings with virtual patients to undergraduate nursing curricula.

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.

Accuracy of online symptom checkers for diagnosis of orofacial pain and oral medicine disease

PURPOSE

The aim of this study was to compare and contrast the diagnostic accuracy of multiple online symptom checkers when used for the diagnosis of orofacial pain and oral medicine related disease vignettes. The comparison condition used in this study was the diagnostic accuracy achieved by advanced specialty residents on these same vignettes using a virtual patient system.

METHODS

27 individual disease vignettes were utilized. These vignettes had a variety of orofacial pain and oral medicine diseases. Post graduate orofacial pain and oral medicine residents at our University of Southern California interacted with their randomly assigned virtual patients were analyzed [n=574]. Virtual patient accuracy was based on whether the user selected the primary diagnosis as one of their top four choices after interviewing. Eleven English-language symptom checkers accuracy was based on whether the vignettes produced the primary diagnosis as one of their top four choices. Using these data, symptom checker and virtual patient accuracy rates were calculated.

RESULTS

The primary diagnosis on virtual patient encounters was found within the top four choices a mean of 67.2% of the time. The primary diagnosis for the same vignettes entered into the 11 symptom checkers was found within the top four choices a mean of 5.9% of the time.

CONCLUSIONS

The accuracy of currently available symptom checkers that patient might use for self-diagnosis of common orofacial pain and oral medicine diseases was low, this result suggest that the improved diagnostic algorithms are needed.

Virtual patient simulation in breaking bad news training for medical students

OBJECTIVE

The present study explores students' perspective on the added value of a virtual patient (VP) simulation as part of a breaking bad news training in undergraduate medical education.

METHODS

The VP simulation allows trying out and practicing different ways of disclosing a cancer diagnosis to a VP (avatar) and to react to emotionally-laden patient statements with the opportunity of self-observation through video recording. After testing the simulation, 23 students shared their experience in focus groups analyzed using thematic analysis.

RESULTS

Self-observation is the most valued feature of the simulation, because it enables users to reflect on their behaviors and adjust them. The competences developed are otherwise technical (e.g., organization of information) and concern less interactional competences. Areas for improvement of the simulation are the interactivity, quality, and diversity of the VPs.

CONCLUSION

The findings show that VP simulations help develop technical communication competences and are best suited as add-ons to other forms of training, in which relational aspects can be targeted. Self-observation is especially valued because it allows for a critical view regarding one's own communication behaviors in a stress-free environment.

PRACTICE IMPLICATIONS

The proposed simulation is beneficial as an add-on to lectures, supervision, and simulated patient interviews.

Use of a virtual patient simulation program to enhance the physical assessment and medical history taking skills of doctor of pharmacy students

INTRODUCTION

To evaluate if utilizing a virtual simulated patient program in a required pharmacy course improves the health history taking and physical assessment skills of first-year professional pharmacy students.

METHODS

During a 14-week course students registered for a web-based virtual patient simulation program. Students were assigned a virtual patient case to complete during weeks one and 13 of the course. Scores from the pre- and post-interventions were compared focusing on the students' ability to perform a physical exam, take a medical history, provide patient education, and display empathy. Students were also asked to self-assess their skills after having been exposed to the virtual simulation program throughout the semester.

RESULTS

The total number of paired observations used in the final analysis of the pre- and post-virtual patient test case was 171 students. The overall student performance index, which includes the scoring of subjective/objective data and patient education/empathy, improved from 52% at week one to 78.42% at week 14. The individual scoring of subjective/objective data and patient education/empathy significantly improved from week one to week 13. Approximately 76.54% of the class strongly agreed or agreed that the virtual simulation program made them feel more confident in their ability to obtain a medical history from patients.

CONCLUSIONS

Virtual patient simulation programs are effective teaching methods for students to develop and improve upon their medical history taking and physical assessment skills.

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.

Virtual patients versus small-group teaching in the training of oral and maxillofacial surgery: a randomized controlled trial

BACKGROUND

Computerized virtual patients (VP) have spread into many areas of healthcare delivery and medical education. They provide various advantages like flexibility in pace and space of learning, a high degree of teaching reproducibility and a cost effectiveness. However, the educational benefit of VP as an additive or also as an alternative to traditional teaching formats remains unclear. Moreover, there are no randomized-controlled studies that investigated the use of VP in a dental curriculum. Therefore, this study investigates VP as an alternative to lecturer-led small-group teaching in a curricular, randomized and controlled setting.

METHODS

Randomized and controlled cohort study. Four VP cases were created according to previously published design principles and compared with lecturer-led small group teaching (SGT) within the Oral and Maxillofacial Surgery clerkship for dental students at the Department for Cranio-, Oral and Maxillofacial Plastic Surgery, Goethe University, Frankfurt, Germany. Clinical competence was measured prior (T0), directly (T1) and 6 weeks (T2) after the intervention using theoretical tests and a self-assessment questionnaire. Furthermore, VP design was evaluated using a validated toolkit.

RESULTS

Fifty-seven students (VP = 32; SGT = 25) agreed to participate in the study. No competence differences were found at T0 (p = 0.56). The VP group outperformed (p < .0001) the SGT group at T1. At T2 there was no difference between both groups (p = 0.55). Both interventions led to a significant growth in self-assessed competence. The VP group felt better prepared to diagnose and treat real patients and regarded VP cases as a rewarding learning experience.

CONCLUSIONS

VP cases are an effective alternative to lecture-led SGT in terms of learning efficacy in the short and long-term as well as self-assessed competence growth and student satisfaction. Furthermore, integrating VP cases within a curricular Oral and Maxillofacial Surgery Clerkship is feasible and leads to substantial growth of clinical competence in undergraduate dental students.

Curriculum integration of virtual patients

BACKGROUND AND PURPOSE

Virtual patients (VP) offer an enhanced learning experience for students to assume the role of health professional and make therapeutic decisions in a simulated environment. While VPs are valued by students and offer benefits to the learner, little is known about how best to implement them in pharmacy education curricula. The purpose of our study was to investigate students' perceptions of VPs and build understanding about how to optimally implement them in the future.

EDUCATIONAL ACTIVITY AND SETTING

Four VP cases were implemented over the first three years of the entry to practice doctor of pharmacy program. Each case was focused on a different condition and implemented in one of three settings (i.e. integration activities, large lecture setting, or independent review). Students were invited to complete a survey and participate in a focus group after completing the patient case.

FINDINGS

One-hundred eighty students completed the survey and six students participated in a focus group. Ninety-four percent of respondents strongly agreed/agreed that VPs were valuable for their learning. Students preferred the VP cases be implemented in small-group settings and be relevantly timed with course material. Students found helpful that cases were realistic, clear, comprehensive, engaging, and incorporated feedback. Perceived benefits included enhanced learning about medical conditions, development of clinical reasoning skills and processes for working through cases.

SUMMARY

VPs continue to be identified as a valuable learning experience. When implemented it is important to consider the learner setting in order to get the greatest value from their use.

Curricular integration of virtual patients: a unifying perspective of medical teachers and students

BACKGROUND

Virtual Patients (VPs) may improve cognitive and behavioral skills better than traditional methods do. The aim of this paper was to investigate challenges faced by teachers and students in order to effectively implement VPs across undergraduate and postgraduate curricula. In addition, differences in student and teacher perceptions that could impact curricular integration of VPs were explored.

METHODS

A two-phase descriptive study was performed: 1) evaluation of the VP design process and curricular integration, conducted upon academic medical teachers; 2) evaluation of learning and clinical reasoning experiences with VPs, from the students' perspective.

RESULTS

The results of this study document high acceptance of VPs by both medical teachers and students (n = 252).VPs seem to fulfill most needs as set by course directors, while they satisfy student needs and create perceptions of improved knowledge and clinical skills reasoning.

CONCLUSIONS

Medical educators have encountered educational challenges upon transforming the curriculum. To develop VPs, academic institutions have to pay equal attention to the needs of potential adopters and VP authors. Strategic development and use of VPs may motivate more widespread integration of VPs and lead to a high quality medical education system.

Optimising mechanical ventilation through model-based methods and automation

Mechanical ventilation (MV) is a core life-support therapy for patients suffering from respiratory failure or acute respiratory distress syndrome (ARDS). Respiratory failure is a secondary outcome of a range of injuries and diseases, and results in almost half of all intensive care unit (ICU) patients receiving some form of MV. Funding the increasing demand for ICU is a major issue and MV, in particular, can double the cost per day due to significant patient variability, over-sedation, and the large amount of clinician time required for patient management. Reducing cost in this area requires both a decrease in the average duration of MV by improving care, and a reduction in clinical workload. Both could be achieved by safely automating all or part of MV care via model-based dynamic systems modelling and control methods are ideally suited to address these problems. This paper presents common lung models, and provides a vision for a more automated future and explores predictive capacity of some current models. This vision includes the use of model-based methods to gain real-time insight to patient condition, improve safety through the forward prediction of outcomes to changes in MV, and develop virtual patients for in-silico design and testing of clinical protocols. Finally, the use of dynamic systems models and system identification to guide therapy for improved personalised control of oxygenation and MV therapy in the ICU will be considered. Such methods are a major part of the future of medicine, which includes greater personalisation and predictive capacity to both optimise care and reduce costs. This review thus presents the state of the art in how dynamic systems and control methods can be applied to transform this core area of ICU medicine.

A simulation-based method to determine optimal sampling schedules for dosimetry in radioligand therapy

AIM

For dosimetry in radioligand therapy, the time-integrated activity coefficients (TIACs) for organs at risk and for tumour lesions have to be determined. The used sampling scheme affects the TIACs and therefore the calculated absorbed doses. The aim of this work was to develop a general and flexible method, which analyses numerous clinically applicable sampling schedules using true time-activity curves (TACs) of virtual patients.

METHOD

Nine virtual patients with true TACs of the tumours were created using a physiologically-based pharmacokinetic (PBPK) model and individual biokinetic data of five patients with neuroendocrine tumours and four with meningioma. ¹¹¹In-DOTATATE was used for pre-therapeutic dosimetry. In total, 15,120 sampling schemes, each consisting of 4 time points, were investigated. Gaussian noise of different levels was added to the corresponding true time-activity points. A bi-exponential function was used to fit the simulated time-activity data. For each investigated sampling schedule, 1000 replications were performed. Patient-specific and population-specific optimal sampling schedules were determined using the relative root-mean-square error (rRMSE). Furthermore, the fractions of TIACs a˜ deviating >5% (f_Δa˜>5%) and >10% (f_Δa˜>10%) from the true TIAC a˜_true were used for additional evaluations e.g. to investigate the effect of varying single time points.

RESULTS

Almost all patient-specific and all population-specific optimal sampling schedules have t₄≥96h for all noise levels. Changing the latest time point from the population-specific optimal time to e.g. 48h leads to a median increase of f_Δa˜>10% from 0.1% to 88% for the lowest investigated noise level. Using the determined population-specific optimal schedules, results in more accurate and precise results than established schedules from the literature.

CONCLUSION

A method of determining the optimal sampling schedule for dosimetry, which considers clinical working hours and measurement uncertainties, has been developed and applied. The simulation study shows that optimised sampling schedules result in high accuracy and precision of the determined TIACs.

Animation and interactivity facilitate acquisition of pediatric life support skills: a randomized controlled trial using virtual patients versus video instruction

BACKGROUND

Several promising studies suggest a positive impact of interactive and media-enriched e-learning resources such as virtual patients (VP) on skill acquisition in pediatric basic life support (PBLS). This study investigates which immanent VP components account for this effect.

METHODS

N = 103 medical students in their 5th year were assigned to one of three groups: a video group prepared with self-instructional videos on PBLS (N = 37); an animation-enriched VP group with VP containing interactive questions (N = 35), static and animated media, and a static VP group with VP containing interactive questions and only static media (N = 31). Subsequent PBLS demonstrations were video-documented and scored for adherence to guideline-based algorithm, temporal demands (such as correct pace of rescue breaths and chest compressions), and quality of procedural steps (e.g., correct head positioning), as well as overall competency by two group-blinded, independent pediatricians.

RESULTS

Groups did not differ with regard to adherence to correct algorithm (88.7 ± 10.3, 93.3 ± 6.7 and 90.3 ± 10.5, respectively). Self-instruction with animated media - through videos or animation-enriched VP - resulted in a better adherence to temporal demands, as compared with training with static VP (64.5 ± 26.3 and 50.7 ± 25.7, respectively, vs. 23.8 ± 21.0). Procedural quality by the video group was slightly inferior compared with the animation-enriched VP group (79.5 ± 12.3 vs. 82.0 ± 11.9), and distinct inferior in overall 'competent' ratings (43.2% vs. 65.7%). The static VP group performed considerably most poorly of all three groups (temporal adherence 73.2 ± 11.9 and 19.4% 'competent' ratings).

CONCLUSIONS

VP can feasibly enhance PBLS skill acquisition. Thoughtful design of animations and interactivity of the VP further improves such skill acquisition, both in quality of performance and in adherence to temporal demands.

The virtual patient as a learning tool: a mixed quantitative qualitative study

BACKGROUND

The use of simulation in medical education has been widely accepted. There are different types of medical simulators that vary in both accuracy to emulate the real world (fidelity) and cost of development or acquisition. There is significant evidence that supports the use of high-fidelity simulators (i.e. mannequins or dummies) to prepare students for clinical environments, less attention has been given to low-fidelity simulators. This article aims to present evidence regarding the effectiveness of a low-fidelity simulator: Virtual Patient (VP), which develops several interactive computer-based clinical scenarios, seeking to promote an alternative learning environment and the development of necessary medical skills such as clinical reasoning in students of medicine.

METHODS

A quasi-experimental study was designed to investigate the results on the development of history taking and clinical reasoning skills in a group of undergraduate medical students, in a course devised under the concepts of constructivism in education, which used the Virtual Patient as the fundamental teaching tool. Results were measured through a mixed, quantitative and qualitative study, triangulating the results of the students' skills evaluation when facing a clinical case represented by an actor patient before and after the course. Additionally, the description of the students' and tool's performance was measured by way of a qualitative study.

RESULTS

The comparison of the students' skills on the evaluation matrix before-and-after the course evidenced a statistically significant advance (p < 0.01) in all aspects (interview, physical exam, clinical judgment, relevance of medical exams, and presentation of case). Students described the VP as an easy-to-use and motivating tool for learning without stress, especially at the beginning of their career. VP allowed them to create logical and structured processes, to be wrong without consequences, and to review and reassess information available. From the professor perspective, it allowed a better follow-up of the students' learning process and favored reflections on the teaching-learning process.

CONCLUSIONS

VP proved to be a valuable and useful tool for the development of clinical reasoning and history taking skills in medical students, as part of a constructivist learning course.

Simulating Clinical Psychiatry for Medical Students: a Comprehensive Clinic Simulator with Virtual Patients and an Electronic Medical Record System

OBJECTIVE

A number of programs representing virtual patients for use in teaching settings have been developed in the field of psychiatry; however, they simulate only the interview process, not the entire scope of treatment. The authors have developed software through which students can experience the practice of psychiatry (in particular, with dementia patients) in its entirety. This study compares this software with conventional learning methods.

METHOD

The control group was 43 fifth-year medical students in 2014 who studied using a conventional learning method (taking lectures and being in contact with actual patients). The experimental group was 36 fifth-year medical students in 2015 that used computer software (taking lectures and with reduced time in contact with actual patients). The authors compared the two groups. Each group was tested before and after clinical training on their acquisition of knowledge of dementia. The control group was tested in 2014, and the experimental group was tested in 2015.

RESULTS

The difference in average test scores between the two groups was statistically significant (p = 0.01), with the experimental group scoring higher.

CONCLUSIONS

The results indicate that students who were taught using a computer-based software method were better able to answer a standard series of questions designed to evaluate their understanding of dementia than those who were taught in a conventional manner. This study demonstrated that there is a possibility to improve education in the field of psychiatry using a comprehensive clinic simulator.

Evaluation of virtual patient cases for teaching diagnostic and management skills in internal medicine: a mixed methods study

Objective

The virtual patient (VP) is a computer program that simulates real-life clinical scenarios and allows learners to make diagnostic and therapeutic decisions in a safe environment. Although many VP cases are available, few focus on junior trainees as their target audience. In addition, there is wide variability in trainees’ clinical rotation experiences, based on local practice and referral patterns, duty hour restrictions, and competing educational requirements. In order to standardize clinical exposure and improve trainees’ knowledge and perceived preparedness to manage core internal medicine cases, we developed a pool of VP cases to simulate common internal medicine presentations. We used quantitative and qualitative analyses to evaluate the effectiveness of one of our VP cases among medical trainees at University of Toronto. We also evaluated the role of VP cases in integrated teaching of non-medical expert competencies.

Results

Despite modest effects on knowledge acquisition, a majority of participants enjoyed using VP cases as a resource to help them prepare for and reinforce clinical experiences. Cognitive interactivity and repetitive practice were particularly appreciated by study participants. Trainees perceived VP cases as a useful resource as their learning can be customized to their actions within the case, resulting in unique learning trajectories.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3463-x) contains supplementary material, which is available to authorized users.

Digital Tools to Enhance Clinical Reasoning

Physicians can improve their diagnostic acumen by adopting a simulation-based approach to analyzing published cases. The tight coupling of clinical problems and their solutions affords physicians the opportunity to efficiently upgrade their illness scripts (structured knowledge of a specific disease) and schemas (structured frameworks for common problems). The more times clinicians practice accessing and applying those knowledge structures through published cases, the greater the odds that they will have an enhanced approach to similar patient-cases in the future. This article highlights digital resources that increase the number of cases a clinician experiences and learns from.

Sensor-Augmented Pump-Based Customized Mathematical Model for Type 1 Diabetes

BACKGROUND

Simulations using mathematical models are important for studying, developing, and improving therapies for people with type 1 diabetes.

METHODS

The Medtronic CareLink^® database was used to create virtual patients with a variety of inter-insulin sensitivities, meal absorption rates, pharmacokinetics, age, and gender. In addition, intra-insulin sensitivities of the virtual patients change over a 24-h cycle.

RESULTS

A total of 2087 virtual patients were developed. The time percentage between 70 and 180 mg/dL of the CareLink uploads and the simulated virtual patients was 72.4% (18.6) and 74.1% (16.9), respectively. The time percentage <70 mg/dL of the real continuous glucose monitoring from CareLink uploads and the simulated virtual patients was 1% (2.4) and 1.7% (4.1), respectively. A simulation study with the virtual patients predicted the glycemic distribution after 2 h of insulin suspension as reported in the ASPIRE (Automation to Simulate Pancreatic Insulin Response) clinical trial. The 3 months outcomes of Medtronic's hybrid closed-loop 670G system pivotal trial were also predicted in a simulation study. The time percentage <70 mg/dL was 3.4% and 3.1%, and the time percentage between 71 and 180 mg/dL was 73.8% and 77.7% for 93 pivotal study adults (>18 years) and 90 adult (>28 years) virtual patients, respectively.

CONCLUSION

The Medtronic CareLink database was utilized to generate a large number of virtual patients with a variety of insulin sensitivities, pharmacokinetics, and meal absorption rates. This new simulation model can be potentially used to evaluate and prognosticate the outcomes of studies of artificial pancreas algorithms and systems.

Modelling Feedback in Virtual Patients: An Iterative Approach

Virtual Patients (VPs) offer learners the opportunity to practice clinical reasoning skills and have recently been integrated in Massive Open Online Courses (MOOCs). Feedback is a central part of a branched VP, allowing the learner to reflect on the consequences of their decisions and actions. However, there is insufficient guidance on how to design feedback models within VPs and especially in the context of their application in MOOCs. In this paper, we share our experiences from building a feedback model for a bladder cancer VP in a Urology MOOC, following an iterative process in three steps. Our results demonstrate how we can systematize the process of improving the quality of VP components by the application of known literature frameworks and extend them with a feedback module. We illustrate the design and re-design process and exemplify with content from our VP. Our results can act as starting point for discussions on modelling feedback in VPs and invite future research on the topic.

Computer model for the cardiovascular system: development of an e-learning tool for teaching of medical students

BACKGROUND

This study combined themes in cardiovascular modelling, clinical cardiology and e-learning to create an on-line environment that would assist undergraduate medical students in understanding key physiological and pathophysiological processes in the cardiovascular system.

METHODS

An interactive on-line environment was developed incorporating a lumped-parameter mathematical model of the human cardiovascular system. The model outputs were used to characterise the progression of key disease processes and allowed students to classify disease severity with the aim of improving their understanding of abnormal physiology in a clinical context. Access to the on-line environment was offered to students at all stages of undergraduate training as an adjunct to routine lectures and tutorials in cardiac pathophysiology. Student feedback was collected on this novel on-line material in the course of routine audits of teaching delivery.

RESULTS

Medical students, irrespective of their stage of undergraduate training, reported that they found the models and the environment interesting and a positive experience. After exposure to the environment, there was a statistically significant improvement in student performance on a series of 6 questions based on cardiovascular medicine, with a 33% and 22% increase in the number of questions answered correctly, p < 0.0001 and p < 0.001 respectively.

CONCLUSIONS

Considerable improvement was found in students' knowledge and understanding during assessment after exposure to the e-learning environment. Opportunities exist for development of similar environments in other fields of medicine, refinement of the existing environment and further engagement with student cohorts. This work combines some exciting and developing fields in medical education, but routine adoption of these types of tool will be possible only with the engagement of all stake-holders, from educationalists, clinicians, modellers to, most importantly, medical students.

"It's like rotations, but in the classroom": Creation of an innovative course to prepare students for advanced pharmacy practice experiences

BACKGROUND AND PURPOSE

The purpose of this article is to discuss the course development and results of a survey assessing students' perceived confidence in performing various skills after completion of this course.

EDUCATIONAL ACTIVITY AND SETTING

The course was taught using a model in which all activities performed by students took place in a fictitious health system. The course was created to give students the opportunity to learn in an environment that closely mimicked advanced pharmacy practice experiences (APPEs) while in the didactic setting. Higher order active learning activities and case-based exams were utilized in the course. Students' perceived level of confidence in performing skills practiced in the course was assessed via survey after completion of each semester of the course and after the first introductory pharmacy practice experience (IPPE). Course coordinators hypothesized that this course design would improve students' perceived level of confidence in performing skills utilized in the clinical practice setting.

FINDINGS

Survey data from two class cohorts were analyzed. Students' perceived level of confidence in performing skills necessary in clinical practice increased as a result of the course.

DISCUSSION

This course provided students an opportunity to experience an APPE environment while still in the didactic setting. The course design meets the Center for the Advancement of Pharmacy Education (CAPE) outcomes and aids in making students "APPE-ready" prior to the start of the P4 year.

SUMMARY

This unique and innovative course format allowed students to integrate knowledge learned in previous courses and apply it in a manner like what is expected in the clinical setting.

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.

Virtual patients in the acquisition of clinical reasoning skills: does presentation mode matter? A quasi-randomized controlled trial

BACKGROUND

The objective of this study is to compare two different instructional methods in the curricular use of computerized virtual patients in undergraduate medical education. We aim to investigate whether using many short and focused cases - the key feature principle - is more effective for the learning of clinical reasoning skills than using few long and systematic cases.

METHODS

We conducted a quasi-randomized, non-blinded, controlled parallel-group intervention trial in a large medical school in Southwestern Germany. During two seminar sessions, fourth- and fifth-year medical students (n = 56) worked on the differential diagnosis of the acute abdomen. The educational tool - virtual patients - was the same, but the instructional method differed: In one trial arm, students worked on multiple short cases, with the instruction being focused only on important elements ("key feature arm", n = 30). In the other trial arm, students worked on few long cases, with the instruction being comprehensive and systematic ("systematic arm", n = 26). The overall training time was the same in both arms. The students' clinical reasoning capacity was measured by a specifically developed instrument, a script concordance test. Their motivation and the perceived effectiveness of the instruction were assessed using a structured evaluation questionnaire.

RESULTS

Upon completion of the script concordance test with a reference score of 80 points and a standard deviation of 5 for experts, students in the key feature arm attained a mean of 57.4 points (95% confidence interval: 50.9-63.9), and in the systematic arm, 62.7 points (57.2-68.2), with Cohen's d at 0.337. The difference is statistically non-significant (p = 0.214). In the evaluation survey, students in the key feature arm indicated that they experienced more time pressure and perceived the material as more difficult.

CONCLUSIONS

In this study powered for a medium effect, we could not provide empirical evidence for the hypothesis that a key feature-based instruction on multiple short cases is superior to a systematic instruction on few long cases in the curricular implementation of virtual patients. The results of the evaluation survey suggest that learners should be given enough time to work through case examples, and that caution should be taken to prevent cognitive overload.

Utilization of a virtual patient for advanced assessment of student performance in pain management

BACKGROUND AND PURPOSE

To assess student performance and achievement of course objectives following the integration of a virtual patient case designed to promote active, patient-centered learning in a required pharmacy course.

EDUCATIONAL ACTIVITY AND SETTING

DecisionSim™ (Kynectiv, Inc., Chadsford, PA), a dynamic virtual patient platform, was used to implement an interactive patient case to augment pain management material presented during a didactic session in a pharmacotherapy course. Simulation performance data were collected and analyzed. Student exam performance on pain management questions was compared to student exam performance on nearly identical questions from a prior year when a paper-based case was used instead of virtual patient technology.

FINDINGS

Students who performed well on the virtual patient case performed better on exam questions related to patient assessment (p = 0.0244), primary pharmacological therapy (p = 0.0001), and additional pharmacological therapy (p = 0.0001). Overall exam performance did not differ between the two groups. However, students with exposure to the virtual patient case demonstrated significantly better performance on higher level Bloom's Taxonomy questions that required them to create pharmacotherapy regimens (p=0.0005). Students in the previous year (exposed only to a paper patient case) performed better in calculating conversions of opioids for patients (p = 0.0001).

SUMMARY

Virtual patient technology may enhance student performance on high-level Bloom's Taxonomy examination questions. This study adds to the current literature demonstrating the value of virtual patient technology as an active-learning strategy.

Measuring interprofessional competencies and attitudes among health professional students creating family planning virtual patient cases

BACKGROUND

The Virtual Interprofessional Patients-Computer-Assisted Reproductive Health Education for Students (VIP-CARES) Project took place during the summers of 2010-2012 for eight weeks each year at the University of British Columbia (UBC). Undergraduate health care students worked collaboratively to develop virtual patient case-based learning modules on the topic of family planning. The purpose of this study was to evaluate the changes in perception towards interprofessional collaboration (IPC) among the participants, before and after the project.

METHODS

This study utilized a mixed methods evaluation using self-assessment survey instruments, semi-structured interviews, and reflective essays. Pre- and post- project surveys were adapted from the Canadian Medical Education Determinants (CanMEDS) and Canadian Interprofessional Health Collaborative (CIHC) frameworks, as well as the Memorial University Interprofessional Attitudes (IPA) questionnaire. The survey results were analyzed as mean (M) and standard deviation (SD) on Likert scales. The non-parametric Wilcoxon signed-rank test was used to determine if any significant changes were measured between each participant's differences in score (p ≤ 0.05). Post-project interview transcripts and essays were analyzed using recursive abstraction to elicit any themes.

RESULTS

Altogether, 26 students in medicine, pharmacy, nursing, midwifery, dentistry, counselling psychology, and computer science participated in VIP-CARES, during the three years. Student attitudes toward IPC were positive before and after the project. At the project's conclusion, there was a statistically significant increase in the participants' self-assessment competency scores in the CanMEDS roles of health advocate (p = 0.05), manager (p = 0.02), and medical expert (p = 0.03), as well as the CIHC domains of interprofessional communication (p = 0.04), role clarification (p = 0.01), team functioning (p = 0.05), and collaborative leadership (p = 0.01). Qualitative evaluations yielded three major themes: communication and respect as key to team functioning, importance of role clarification within the team, and existence of inherent challenges to IPC. From the reflections, students generally felt more comfortable with their improvements in the CIHC domains of interprofessional communication, team functioning, and role clarification.

CONCLUSION

After working within an interdisciplinary team developing virtual patient learning modules on family planning, the student participants of the VIP-CARES Project indicated general improvement in the skills necessary for effective interprofessional collaboration. Triangulation of the overall data suggests this was especially observed within the areas of interprofessional communication, team functioning, and role clarification.

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.

Dynamics of study strategies and teacher regulation in virtual patient learning activities: a cross sectional survey

BACKGROUND

Students' self-regulated learning becomes essential with increased use of exploratory web-based activities such as virtual patients (VPs). The purpose was to investigate the interplay between students' self-regulated learning strategies and perceived benefit in VP learning activities.

METHOD

A cross-sectional study (n = 150) comparing students' study strategies and perceived benefit of a virtual patient learning activity in a clinical clerkship preparatory course. Teacher regulation varied among three settings and was classified from shared to strong. These settings were compared regarding their respective relations between regulation strategies and perceived benefit of the virtual patient activity.

RESULTS

Self-regulation learning strategy was generally associated with perceived benefit of the VP activities (rho 0.27, p < 0.001), but was not true in all settings. The association was higher in the two strongly regulated settings. The external regulation strategy did generally associate weakly with perceived benefit (rho 0.17, p < 0.05) with large variations between settings.

CONCLUSIONS

The flexible student-autonomous appeal of virtual patients should not lead to the dismissal of guidance and related course activities. External teacher and peer regulation seem to be productive for increasing learners' perceived benefit. Awareness of the interplay among teacher regulation (external) and various study strategies can increase the value of flexible web-based learning resources to students.

Virtual patient simulation in psychiatric care - A pilot study of digital support for collaborate learning

Psychiatric and mental health nursing is built on a trusted nurse and patient relationship. Therefore communication and clinical reasoning are two important issues. Our experiences as teachers in psychiatric educational programmes are that the students feel anxiety and fear before they start their clinical practices in psychiatry. Therefore there is a need for bridging over the fear. Technology enhanced learning might support such activities so we used Virtual patients (VPs), an interactive computer simulations of real-life clinical scenarios. The aim of this study was to investigate 4th term nursing students' opinions on the use of Virtual Patients for assessment in a Mental Health and Ill-health course module. We asked 24 volunteering students to practise with five different VP cases during almost 10 weeks before the exam. The participants were gathered together for participating in a written and an oral evaluation. The students were positive to the use of VPs in psychiatry and were very positive to use VPs in their continued nursing education. It seems that Virtual Patients can be an activity producing pedagogic model promoting students' independent knowledge development, critical thinking, reflection and problem solving ability for nurse students in psychiatric care.

The effect of constructing versus solving virtual patient cases on transfer of learning: a randomized trial

The purpose of this study was to explore the effect of actively constructing virtual patient (VP) cases compared with solving VP cases on knowledge gains, skills transfer and time spent on cases. Forty-five fourth-year medical students were randomized to constructing (VP-construction, n = 23) or solving (VP-solving, n = 22) four cardiopulmonary VP cases. Whereas the VP-solving group solved the cases, the VP-construction group only received the final diagnosis and had to complete the history, physical findings, and lab results. After a week, participants completed a transfer test involving two standardized patients representing cardiopulmonary cases. Performances on the transfer test were video-recorded and assessed by two blinded raters using the Reporter, Interpreter, Manager, Educator (RIME) framework. Thirty-nine participants completed the transfer test. The VP-construction group spent significantly more time on the VP cases compared with the VP-solving group, p = 0.002. There were no significant differences in RIME scores between the VP-construction group and VP-solving group, p = 0.54.In conclusion, engaging novice students in active VP case construction may be more time consuming than solving VP cases, without resulting in superior skills transfer.

Assessing progression of clinical reasoning through virtual patients: An exploratory study

To avoid test-driven learning, there have been discussions regarding the use of more formative assessments in health care education to promote students' deep learning. Feedback is important in formative assessment, but many students ignore it; therefore, interventions should be introduced which stimulate them to reflect on the new knowledge. The aim for this study was to explore if Virtual Patient (VP)-based formative assessments, in connection with self-evaluations, had an impact on postgraduate pediatric nursing students' development of clinical reasoning abilities. Students' self-evaluations served as the basis for measuring progress. Data was analysed using deductive content analysis. The findings showed a clear progression of the clinical reasoning ability of the students. After the first assessment, the students described feelings of uncertainty and that their knowledge gaps were exposed. At the mid-course assessment the awareness of improved clinical reasoning was obvious and the students were more certain of knowing how to solve the VP cases. In the final assessment, self-efficacy was expressed. VP-based assessments, in connection with self-evaluations, early in the education resulted in a gain of students' own identification of the concept of clinical reasoning, awareness of what to focus on during clinical practice and visualised expected clinical competence.

Beyond xMOOCs in healthcare education: study of the feasibility in integrating virtual patient systems and MOOC platforms

Background. Massive Open Online Courses (MOOCs) are an emerging trend in online learning. However, their technology is not yet completely adjusted to the needs of healthcare education. Integration of Virtual Patients within MOOCs to increase interactivity and foster clinical reasoning skills training, has been discussed in the past, but not verified by a practical implementation.

Objective. To investigate the technical feasibility of integrating MOOCs with Virtual Patients for the purpose of enabling further research into the potential pedagogical benefits of this approach.

Methods. We selected OpenEdx and Open Labyrinth as representative constituents of a MOOC platform and Virtual Patient system integration. Based upon our prior experience we selected the most fundamental technical requirement to address. Grounded in the available literature we identified an e-learning standard to guide the integration. We attempted to demonstrate the feasibility of the integration by designing a “proof-of-concept” prototype. The resulting pilot implementation was subject of verification by two test cases.

Results. A Single Sign-On mechanism connecting Open Labyrinth with OpenEdx and based on the IMS LTI standard was successfully implemented and verified.

Conclusion. We investigated the technical perspective of integrating Virtual Patients with MOOCs. By addressing this crucial technical requirement we set a base for future research on the educational benefits of using virtual patients in MOOCs. This provides new opportunities for integrating specialized software in healthcare education at massive scale.

Clinical reasoning in nursing, a think-aloud study using virtual patients - a base for an innovative assessment

In health-care education, it is important to assess the competencies that are essential for the professional role. To develop clinical reasoning skills is crucial for nursing practice and therefore an important learning outcome in nursing education programmes. Virtual patients (VPs) are interactive computer simulations of real-life clinical scenarios and have been suggested for use not only for learning, but also for assessment of clinical reasoning. The aim of this study was to investigate how experienced paediatric nurses reason regarding complex VP cases and how they make clinical decisions. The study was also aimed to give information about possible issues that should be assessed in clinical reasoning exams for post-graduate students in diploma specialist paediatric nursing education. The information from this study is believed to be of high value when developing scoring and grading models for a VP-based examination for the specialist diploma in paediatric nursing education. Using the think-aloud method, data were collected from 30 RNs working in Swedish paediatric departments, and child or school health-care centres. Content analysis was used to analyse the data. The results indicate that experienced nurses try to consolidate their hypotheses by seeing a pattern and judging the value of signs, symptoms, physical examinations, laboratory tests and radiology. They show high specific competence but earlier experience of similar cases was also of importance for the decision making. The nurses thought it was an innovative assessment focusing on clinical reasoning and clinical decision making. They thought it was an enjoyable way to be assessed and that all three main issues could be assessed using VPs. In conclusion, VPs seem to be a possible model for assessing the clinical reasoning process and clinical decision making, but how to score and grade such exams needs further research.