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Alignment of VPs with curricular learning objectives

Guiding questions:

  1. How do I align the VPs with the overarching learning objectives of the curriculum?
  2. How do I make selections of the VPs?
  3. How do I modify the VPs to adjust them to those goals?

One of the most important developments in medical education of the last two decades is the movement towards Outcome-Based Education (OBE) [Holmboe 2021]. Curricula designed following this paradigm start with a clear specification of the intended learning outcomes. All the decisions made regarding the curriculum design, in particular selection of the instructional and assessment methods, should be directed towards achieving the pre-specified learning objectives. This is also known as constructive alignment.

Therefore, when introducing VPs into the curriculum it is very important to first identify the learning objectives (LOs) in the curriculum that are suitable to be addressed with VPs. What those relevant learning objectives are depends on many factors including the mission statement and overarching goals of the curriculum at your university. Some countries may be obliged or strongly recommended to implement specific competency frameworks prescribed by various accreditation bodies. Finally, this may depend on LO-specific disciplines [Radon 2011]. Do not forget to consider also the level of competency of students that you want to introduce the VPs to, or user-specific interests (more information about these topics).

The general guideline is to consider VPs as a valid instructional tool to achieve LOs related to clinical reasoning [Cook 2009, Plackett 2022]. VPs come to the rescue when it gets hard to fulfill LOs because of insufficient inpatients covering specific diagnoses. They can work well as an additional learning source in the absence of real patients or clinical teachers, allowing learning to be continued [Tworek 2010]. However, apart from learning about the management of different diseases, there are also other curricular objectives and themes that may be well implemented with VPs. In particular, these could be cultural competencies [Smith 2011], sex- and gender-specific health [Casanova 2019], care for patients with special needs like developmental disabilities [Sanders 2008], empathic communication with patients [Guetterman 2019] or interprofessional collaboration skills [Edelbring 2022]. 

In an integrated curriculum, VPs can be a useful tool in addressing basic sciences’ LOs for higher motivation to learn it in a clinical context. For instance, while presenting VPs to discuss with the students the pathophysiological mechanisms behind common signs and symptoms you should pay attention to the use of adequate semantic qualifiers. This strategy is likely to facilitate better knowledge encapsulation that leads to more robust clinical reasoning [Woods 2007].

It is also worth emphasizing that VPs are not only suitable for teaching but can also be an assessment method for many LOs [Huwendiek 2008]. We discuss assessment with VPs in a separate theme. However, we would like to stress here, in particular, that if you address a clinical reasoning LOs (so-called higher level thinking) with VPs and then assess the outcome using a knowledge-based multiple-choice question test alone, you should not be surprised to see modest effects as this is not a good example of constructive alignment. It is important to explicitly communicate to the students how the LOs of your VPs contribute to the overall concept of the curriculum [Hege 2007]. What may help is to map existing VPs to the end-of-program outcomes  highlighting where the curriculum objectives will be met, where there is still an option to enhance the learning, and where there are gaps [Altmiller 2021].

If you have the opportunity to edit the VPs, you may wish to adapt them to your particular LOs and target levels of competencies. However, you need to be careful not to lose the authenticity of the VPs, meaning that it should closely relate to the work of the practicing health professional. According to Hirumi et al. (2016), simplifying the interactions within the VP case, will decrease the authenticity, but will also reduce frustration and increase satisfaction with the user interface [Hirumi16]. Furthermore, we have discussed localization of VPs in the section on prioritization of VPs.

Based on the literature and our experiences, there is no defined number of VPs you should put into the curriculum. As the different researchers present their findings, clinical reasoning is problem-specific and there is no generalizable problem-solving algorithm that can be learned [Elstein 1978, Norman 2005]. It means that medical students need to experience in the curriculum a large number of cases with a range of specific medical problems to become competent physicians [Lanphear 2021]. For instance, in one paper, authors have introduced 72 virtual patients in the renewed curriculum at the University of Toronto [Kulasegaram 2018]. The iCoViP collection contains 200 virtual patients [Mayer 2022]. In this paper, we underline that the selection of VPs in such collections should be well thought through and should be attempting to resemble the distribution of diseases in the VP collection to that of the target population of real-life patients to avoid introducing bias to the students. The higher the number of cases you have in your collection (more than 15 cases), the higher the mean satisfaction of students will be [Al-Dosari 2017]. But of course, you should always consider your educational setting, curriculum, and LOs when deciding on the number of VPs.

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