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Relation to other learning activities

We will present here the nature and scope of both related and competing curriculum resources that affect the use of VPs and the impact that they have on student learning.

Guiding questions:

  1. What influence should VPs have on other types of learning activities (like lectures, high fidelity simulations, standardized patients, etc.)?
  2. How should VPs be influenced by those learning activities?

When we think about implementing VPs into our curriculum, we try to consider different options of where or how to use them. ften, the medical or healthcare science curricula are packed with required classes. If the assumption is that the VP should replace some other activity, what should it be? Or, if the assumption is that the VP should be used in combination with some other activity, what should it be and how should this combination look like? If the VP activities and supplementing activities should be presented in a specific order (including time spaces between the activities) what should it be? Below we will try to answer these questions.

Relation to other learning activities

In this section we will try to focus on situations where we want to introduce VPs as an addition to other, already existing learning activities. What should be the combination and what should it look like?

Any integration process of VPs into the curriculum must be carefully planned, implemented and evaluated. To be successful, e-learning resources like VPs, in particular, must be integrated and aligned with the desired learning objectives [Baumann-Birkbeck 2017] and other teaching events [Haag 2010] like cardiac auscultation exercises on mannequins [Quinn 2011] or radiological course programs [Scherer 2011]. As stated by Huwendiek et al., those activities should be built on each other to give the students an opportunity to apply newly gained knowledge [Huwendiek 2013].

VPs can be used in very different settings. Cases can be included in all learning environments being particularly suitable to small groups, larger interactive classroom teaching sessions and individual learning. VP cases can be used as a prerequisite for high-fidelity simulations [Singh 2003] or may be used as an assessment method of intended learning outcomes. Students prefer to have the VPs introduced after rather than during the lectures, which they call “an incompatible setting” for the experience of working through cases [Dahri 2019]. It is possible to combine communication-focused classes or mannequin-based activities by asking students to solve VPs in preparation for high-fidelity simulation. When students are waiting to take their turn on a simulator or enter a role playing activity, give them a VP to solve, which will allow them to stay active and focused throughout that time. Thereby, you can use the existing resources in a better way, enhance different experiences and turn partial-task training into whole-task training [Ellaway 2015].

As noted by Fischer et al., if we use VPs without integrating them into the curriculum, this would lead to low acceptance of such methods. Therefore, exam-relevance of VPs and integration with follow-up seminars are key factors for a high level of acceptance. Fischer et al. presented an example from Munich where internal medicine learning cases ceased to be integrated on a mandatory basis. Instead, students were provided with 15 learning cases that thematically related to a weekly seminar (with 18 students per group) and dealt with content that was relevant to the final written exam. The learning cases were to be worked on in self-study as preparation for the follow-up seminar and discussed there. About 10% of the questions in the final exam referred to case contents [Fischer 2008].

VPs can also be an addition to simulated patients (SPs). As stated by Cendan et al., this solution gives the students the chance to revise the content, to receive individualized feedback, to reflect on the actions taken during the encounter, and to compare their decisions with the best practices protocols or recommended procedures. VPs can be used, for instance, in a situation where the SP cannot demonstrate some of the elements of physical examination findings like cardiac murmurs, abnormal breath sounds, or neurological deficits [Cendan 2012, Johnson 2013]. They can also be used as preparation before either interacting with an SP, where the given feedback might potentially be a powerful educational tool [Stevens 2006], or with real patients, which can give students more confidence. More about feedback will be covered in this section.

In the literature, recommendations can be found on using VPs alongside traditional clinical placements [Menendez 2015]. There is a strong notion that it should complement the bed-side teaching, making it more understandable and meaningful [Edelbring 2011] and also allowing to link the basic sciences with clinical encounters [Posel 2012]. iCoViP partners recommend that VP activities can be given to students during clinical placements when doctors are unavailable. The lack of availability of patients showing a particular clinical presentation during the clerkship can be compensated by a VP experience as suggested by the Liaison Committee on Medical Education (LCME) ED-2 standard [Tworek 2010]. For instance, it can be used on the last day of the clerkship if there are gaps (VP is better than nothing), or in times when clinical teaching and learning is temporarily impossible (i.e.: during the COVID-19 pandemic) [Nascimento 2021].

When we speak about the relation to other learning activities, a relevant component of VPs integration is to organize a follow-up seminar around this activity. According to Zary et al., teacher-led seminars may still play an important role in providing credibility to the VPs [Zary 2009]. Further advantages are that it gives higher effectiveness for learning in terms of deeper discussion within a safe environment, seems to catalyse the case processing and relates the cases to the clinical reality by virtue of the teacher’s clinical perspective [Edelbring 2012].

One of the challenges you may face when introducing VPs into the curriculum is that it cannot be stretched more and some elements will need to be removed to make space for using VPs. But what to choose to not compromise the overall objectives? The current literature reflects this struggle.

If you need to make a decision about removing activities from an existing curriculum to make space for VPs, it is better to replace passive forms of teaching - like lectures or reading exercises - instead of active methods like small group discussions or mannequin-based learning [ Kononowicz 2019]. At the same time some authors remind us that if you uncritically remove some teaching activity, this would not necessarily improve neither the perceived integration nor the learning [Berman 2009, Lang 2013].

With CoViP partners we discussed that a replacement should not be radical and involve a complete withdrawal of an established teaching format for the benefit of VPs rather it should have the form of a partial replacement. For instance, even though lectures have limitations, they still have their role in introducing key knowledge concepts. Yet, the replacement of static case presentations within lectures with VPs was regarded as a reasonable solution. In our iCoViP project discussion around the guidelines the opinion was often voiced that the beauty of teaching comes from preserving diversity of suitable teaching methods.

If you already work with traditional paper-based cases, there is a recommendation to replace them with virtual cases [Cendan 2012]. In a study by Poulton et al. the replacement of paper-based cases by online VPs in PBL sessions was highly appreciated by both students and teachers. Also, students and tutors think that interactive VPs provide a more authentic, immersive experience suited to problem solving [Poulton 2011]. Furthermore, compared to reading a book, the use of VPs was found to trigger higher student engagement, and having an extra dimension with the use of video clips of patient presentations. VPs are also a valuable tool in terms of time-efficiency compared to real patients’ interactions or case seminars as well as variation in learning activities, studying “in a different way” as compared to traditional methods [Edelbring 2011].

Students also express preference of VPs over traditional knowledge transfer solutions such as lectures [Dahri 2019, Kolb 2007]. When they have a chance to independently work with VPs (e.g instead of going to lectures), they have the opportunity to self-assess their diagnostic and patient management skills [Ellaway 2011]. According to one of the studies, 78% of students indicated that replacing lectures with virtual patients allowed for better use of faculty contact time with them and 84% of them said that completing the virtual patient prior to class allowed them to become better self-directed learners [Benedict 2013]. Also, it was important to students during clinical clerkships to have some activities removed in order to deal with the additional workload created by the integration of VPs [Huwendiek 2013].

Choosing to move to VPs could solve problems related to financial constraints on materials [Maleck 2001]. The paper-based medium itself can put a strain on tutors: lack of accessibility, the cost and time resources to replicate the patient’s imaging and other materials needed for the paper-based cases. Thanks to moving to VPs we may improve the delivery of patient cases [Zary 2009] and save some resources, while still increasing learning opportunities [Doloca 2016]. As one of our students once summarized about working on a VP module: "you do not have to copy it and you cannot lose it" [Kononowicz 2012]. There is also a strong recommendation to never replace real patient contacts with VPs, unless it is absolutely necessary, which for example we have observed during full lockdown because of the COVID-19 pandemic.In this particular situation, it was done more as a complement than a real replacement. The same applies to situations where the healthcare setting does not provide a patient matching our learning objectives. VPs could complement areas where there are no other suitable learning tools for clinical reasoning and problem solving [Poulton 2011]. Moreover, VPs could be a learning tool directed into a specific task [Edelbring 2011].

In general, when VPs are integrated into existing learning activities or used to replace such activities, the perceived implementation seems to be more successful than when redundant traditional methods are kept in place [Berman 2009] or when VPs are used as additional activities on top of the existing curriculum [Lang 2013].

When you are considering implementation of the VPs in relation to other learning activities, one more factor should be taken into account. It is how we will sequence the VPs with other teaching events. Should they be presented in a specific order (including time spaces between the activities), and what could it be?

Most importantly, try to be flexible in sequencing VPs depending on your needs and the needs of your students, as well as the learning objectives you would like to achieve. It was found that spaced activation contributed to a more balanced (spreaded in time) use of VPs with a lower peak of number of sessions right before the exam [Maier 2013].

If you are considering using the VPs with lectures, you could introduce them before the lecture to activate students’ knowledge; or after - to reinforce it. For instance, in the study of Huwendiek et al. 2013 students preferred working on VPs after the lectures, as it enabled them to apply knowledge from the lecture to the VP. This had another function, it raised students’ confidence and helped them memorize important aspects [Huwendiek 2013]. According to the majority of students (78%), completing the VPs before the class gives an opportunity to use the class time for activities more difficult to complete at distance as hands-on-training or small group discussion, and therefore it stimulates self-directed learning [Baumann-Birkbeck 2017].

In the case of bedside teaching, VPs can be used also in two ways: before meeting a real patient - to gain confidence; or after - for reflection or to discuss errors. As noted by Huwendiek et al. 2013, according to students, it was highly meaningful, motivating and supportive for their learning to work on a VP before an encounter with a real patient with similar symptoms. This made them feel ready and confident to engage in these encounters. Students can plan which questions to ask, what kind of examinations to perform and which differential diagnoses to take into consideration [Huwendiek 2013].

What also may be beneficial, is to let the students work on VPs independently at home, so they can develop their problem-solving skills, and then follow it up with a tutorial with the teacher, where students can sum up their learning, revisit the case, as well as get answers to all of the questions, that may have arisen. Between these two meetings, interdisciplinary lectures use the case as a spring board to cover relevant concepts [Kulasegaram 2018]. Riedel et al. 2003 found that the scenario where first students work in a group of 2-3 per one computer, with the tutor present in the class, and then learn alone at home - was assessed as the best implementation method [Riedel 2003]. There is also another aspect of organizing small group discussions after individual work on VPs. It was found that students take such a solution more seriously, when they know that they are likely to be questioned about the VPs [Huwendiek 2013].

Most probably, there is no one best solution in terms of sequencing when using the VPs. Generally, it is believed that if you sequence a lecture, followed by one or two VPs, then organize a small group discussion and finalize with a real patient encounter, this will give a student maximum support for their learning and optimal preparation [Huwendiek 2013]. Similar recommendation was given by Hirumi et al. 2016 where the integration strategy included a lecture, a demonstration of NERVE [a digital learning environment around cranial nerve disorders knowledge] with explicit expectations and requirements, VPs interactions within the NERVE, an instructor-led AAR [After Action Review, i.e. follow-up seminar] with the entire class, and a standardized patient/virtual patient (SP/VP) hybrid encounter [Hirumi 2016].

– When looking for elements in curricula that can be replaced by VPs focus on passive forms of teaching, like static case presentations in lectures.
– VPs can save money and add more flexibility when replacing paper-based cases. 
– Do not replace real patient encounters with VPs unless you are forced to do that due to extreme conditions like the COVID-19 pandemic or to fill gaps in the clinical experience due to lack of access to particular clinical presentations.
– Use VPs to integrate core knowledge concepts presented in lectures.
– Use VPs as preparations for simulation classes.
– During clinical placements, VPs can be used to fill in gaps caused by lack of availability of patients with specific clinical presentations and in case of limited time of clinical teachers.
– When presenting VPs to students, activate them one at a time with a time gap between them and do not make them available all at once. This will result in a more balanced use of VPs.

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Phase of the curriculum4th year of medical school
Goal in the curriculumThe iCoViP collection was implemented to practice selected VPs in the subject of Occupational Medicine (a voluntary subject in the University of Zaragoza in the 4th year of medical school).
Effective use of resourcesThe collection was used asynchronously so it was not necessary to have a computer infrastructure or a specific room and all students in Spain have laptops or access to the medical school computers. However, issue of updating content not yet solved.
VP alignmentThe collection is used  while students are doing their clinical placements having a teacher revising the responses and explaining to students most frequent mistakes.
Prioritization/relevanceFor Occupational Medicine, the use of the iCoViP collection was a mandatory assignment needed to pass, but did not add points to the final grade.
Relation to other learning activitiesNone
Time allocationOne week was given to complete the assignment but more time was available for those who wanted to do the activity remote from home.
Group allocationStudents worked alone at home, when the educator discussed the solution of the VP, it was allocated in class (face-to-face or online).
Presence modeAsynchronous
Technical IntegrationIt was integrated into Moodle.
VP use orientation/trainingVPs were related to a specialty of medicine, but were randomly assigned to students regardless of where in the specialty they were rotating at the time.
Technical infrastructureWe used the technical infrastructure of the iCoViP project without any additions at the University of Zaragoza.
Learning activities around VPsThe teacher explained each VP and how to resolve them after getting the responses of all the students.
AssessmentStudents had to complete the VPs, but there was no grade at the end. Only credit (pass/fail).
Quality assurance, maintenance, and sustainabilityFrequent revision of the VPs by medical doctors.
Phase of the curriculumYear 3 and 4 of medical school
Goal in the curriculumStudents learn basic steps of clinical reasoning including identifying relevant findings, developing differential diagnoses, deciding about a final diagnosis, ordering tests to rule out / confirm differentials, and suggesting treatment options.
Effective use of resourcesCourse tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs
VP alignmentVPs were part of the modules (e.g. Abdomen, cardiovascular system, pulmonary system, etc.) in year 3 and 4 of medical school and aligned with the objectives of these modules based on key symptoms. In addition a pool of 41 VPs was available for deliberate practice across key symptoms and diagnoses.
Time allocation5 VPs / module
Group allocationStudents could choose whether to work in groups or individually.
Presence modeStudents could decide when and where to work on the VPs during the period of the module.
Technical IntegrationVPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/trainingNo specific familiarization, but general introduction at the beginning of year 3.
Learning activities around VPsDepending on the modules other learning activities were embedded.
AssessmentThe topics of the VPs were part of modules assessment.
Quality assurance, maintenance, and sustainabilityWe used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.
Phase of the curriculumYear 1 and 2 of medical school
Goal in the curriculumStudents learn basic steps of clinical reasoning such as identifying & prioritizing findings and composing a summary statement. They also can follow the reasoning process of the VP author concerning differential diagnoses, ordered tests, and treatments.
Effective use of resourcesCourse tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs.
VP alignmentVPs were part of the longitudinal clinical course and aligned with the other modules in year 1 and 2 (In case of Augsburg this was Contact, Movement, and equilibrium). We aligned the key symptoms of the VPs with these modules, so that students worked in parallel on these VPs and the corresponding module.
Time allocation15 VPs over two years / 5 VPs per module.
Group allocationStudents could choose whether to work in groups or individually.
Presence modeStudents could decide when and where to work on the VPs during the period of the module.
Technical IntegrationVPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/trainingAt the beginning of year 1 students were introduced into clinical reasoning and how they can train this ability with VPs.
Learning activities around VPsDepending on the key symptoms during the longitudinal clinical course other learning activities were embedded.
AssessmentThe topics of the VPs were part of the clinical longitudinal course assessment.
Quality assurance, maintenance, and sustainabilityWe used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.
Phase of the curriculumBasic sciences/pre-clinical years:
- At Jagiellonian University Medical College in Kraków we have integrated it in the “Introduction to Clinical Sciences” course in 2nd year of medicine.
- At University of Porto in the “Propedeutics/Semiology” course in the 3rd year of medicine.
Goal in the curriculum- To provide the students with an opportunity to challenge their knowledge at home in between classes with an interactive, clinical-oriented task.
- To support learning by linking basic science knowledge with clinical reasoning. Students had the opportunity to practice on undiagnosed cases the skill of differentiating common symptoms, such as dyspnea, abdominal pain, headache.
Effective use of resourcesUse of iCoViP VPs in native language of the students. No extra cost needed.
VP alignment- In Kraków we have selected a few VPs (seven) with common diseases (e.g. pneumonia, pancreatitis, pulmonary embolism) with common symptoms.
- In Porto, VPs are chosen according to the common symptoms to promote clinical reasoning.
Prioritization/relevance- In Kraków the completion of all VPs is mandatory.
- In Porto, VPs are introduced on a voluntary basis and are available on demand.
Relation to other learning activitiesWe used the time students had at home between seminars (Kraków: between on-campus based PBL sessions). VPs were spaced-activated (a new VP appeared biweekly synchronized with changing topics of the PBL seminars that focus on different leading symptoms).
Time allocationAround 30 minutes biweekly, repeated 7 times in a semester. 
Group allocationStudents worked alone at home to reflect but could consult the VPs with their peers or instructors in small groups of the face-to-face PBL seminars.
Presence modeStudents worked on the VPs asynchronously and self-directed at home to have time to reflect and consult textbooks.
Technical IntegrationVPs were integrated with a course to which all students were enrolled on the official university learning management system Moodle using Learning Tools Interoperability (LTI) interface.
VP use orientation/trainingStudents were provided with an introductory email with instructions and had additionally the opportunity to technically practice using CASUS in a parallel “Telemedicine” (Medical informatics) course. Instructors received test-codes to practice the VPs at home.
Technical infrastructureStudents used their own computers from home. An email address was provided to a person responsible for technical support.
Learning activities around VPsStudents were asked to complete concept maps for all VPs they solve. Moreover, in Kraków students were provided with links to additional online articles to help them with topics difficult at this stage of education.
AssessmentStudents were asked to complete the cases prior to the end of the term. They were not given grades for the activity - just credit. Their answers were randomly inspected to see common mistakes and provide general feedback to all students.
Quality assurance, maintenance, and sustainabilityWe checked the diagnostic accuracy of individual cases (and detected one case with imprecise diagnosis). Students evaluated the course using the iCoViP case collection evaluation questionnaire.
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