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Limited Resources

Guiding questions:

  1. How to deal with barriers due to limited funds?
  2. How to deal when you do not have enough expertise?
  3. What to do when you have no computer rooms or other elements of technical infrastructure?

One of the often quoted barriers in implementation of virtual patients are their costs. In a well known study carried out at U.S. and Canadian universities by Huang et al. [Huang 2007] the average costs of developing one virtual patient were reported to be in the range of $10,000 – 50,000 without maintenance costs. Other types of costs include: faculty development, teacher salaries, IT infrastructure and staff, classroom use, etc. Altogether it amounts to a total that appears to many teachers as an insurmountable barrier. How to deal with that?

The costs of virtual patients should of course not be ignored, but the good news is that with enough determination there are ways to deal with this issue. The best proof for that is the fact that virtual patients are reported to be in use on all continents (except Antarctica) both in countries with high and low income [Kononowicz 2019]. Below are a few tips on how to succeed if the budget for virtual patients is very limited.

First, it is important to reduce expectations of perfection in aesthetics and technical sophistication. The entertainment industry and press releases reporting on innovative virtual reality research projects create a demand unrealistic to satisfy on graphical fidelity in virtual patient persona and the simulated clinical environment. Many expect virtual patients to contain very advanced artificial intelligence-based functions e.g. in natural language processing for history taking. This is of course all impressive and interesting, but to get a good learning outcome it is often unnecessary. In fact, there are studies published that fail to show any improvement in learning outcomes with growing technical sophistication of the virtual patient simulation [Dankbaar 2016]. Some features of virtual worlds may actually be more a distraction than help. High technical requirements lead to problems in simulation accessibility (e.g. when external Internet connections are blocked, there is no possibility to install plugins or require expensive non-standard computer equipment like VR headsets) [Conradi 2009]. It might help to be clear from the very beginning that introducing virtual patients in the curriculum is not about impressing one with technology or entertaining, but about learning what is relevant in clinical reasoning in a flexible and interactive way.

The notion that virtual patients require dedicated computer labs to implement is nowadays largely outdated. The availability of computers or mobile devices at students’ homes is wide-spread. Taking advantage of this is an obvious way when you plan to implement virtual patients as part of the online preparatory activities in the flipped classroom model. If you need to be available in person for feedback while they are learning, you may suggest a “bring your own device” class when students have one shared laptop for a team brought by a group member. Of course this works only in the case you do not insist on the use of technically sophisticated virtual patient solutions requiring for instance virtual reality headsets or high bandwidth Internet connections as discussed above. But, for instance CASUS, the virtual patient system in use to host the iCoViP collection, requires for execution a plain web browser and works across all common operating system platforms. This is also true for several other virtual patient platforms such as OpenLabyrinth or DecisionSim.

Another way of reducing costs is to collaborate and share both resources and experiences. The history of virtual patients is full of examples of initiatives in which universities from one or several countries team up to jointly create, repurpose or support themselves in using virtual patients. Good examples could be projects like CLIPP [Fall 2005], NetWoRM [Kolb 2007], eViP [Poulton 2011], the MEFANET network [Majernik 2016] and many more. Of course, the iCoViP project in the context of which these guidelines and the virtual patient collection have been developed, being a collaboration of six universities, is also an example of a shared effort. The results of such consortia are often publicly available on the Internet for several years after the project has ended. So the next tip is to search online for free content and tools. If not found, maybe you can reduce the cost of developing virtual patients by sharing the effort with partners in a project or network you join. 

You can also learn the know-how in a cost-effective way from the experiences of other universities. Dewhurst et al. describe for instance how virtual patients have been implemented at several universities in Malawi [Dewhurst 2009]. The key to success was a series of workshops organized by visiting instructors from Scotland for those who just started the use of virtual patients in Africa. Another example of a long lasting international collaboration is the MEFANET initiative of Czech and Slovak universities who organize regular annual meetings to discuss experience in using e-learning resources, including virtual patients [Majernik 2016]. Kolb et al. reported about an international collaboration with many European universities in the area of virtual patients for occupational medicine [Kolb 2007]. MedBiquitous is a US-based international organization to support technical standards and good practice in the field of computer-aided medical education. In order to save time and money you should avoid doing repetitive work for example by joining a community that shares the same goals related to virtual patients as you have. 

Some of the work can be completed in collaboration with students who can help in development, translations and integration of virtual patients with minimal supervision of experts. For instance, in the project NetWoRM LA Students from Germany annually visited partner universities from Latin America (Brasil, Chile) to create virtual patients in collaboration with local experts. It turned out that those virtual patients were more interesting and motivating for users than VPs created by teachers [Radon 2011]. For students, collaboration in such initiatives is rewarding as a learning by teaching scenario, an opportunity to collect international experiences and to improve intercultural understanding.

The tools you use to support teaching with virtual patients – for instance an e-portfolio system, tools for creation of concept maps or discussion boards do not need to be a commercial solution. There are several open source or freely available tools like Cmap, Moodle, Mahara or Padlet in use that can be used to support activities. If you need to enrich the existing virtual patients with new multimedia instead of developing those from scratch, you can also look for free images and videos under Creative Commons license (e.g. on Flickr) or in low cost stock photography services (e.g. Shutterstock).

Finally, some of those who complain about the costs of virtual patients forget that the alternative to virtual patients also costs money, sometimes more than what is required for virtual patients. As discussed in other parts of this guideline, medical curricula are often already filled to the brim and the introduction of virtual patients is only possible when some other activities are replaced. The money that is saved by discarding one type of education can be relocated to the new type. Traditional education also requires classrooms and teacher time for preparing and conducting the classes. The advantage of online resources is that after an initial investment to implement the resources, they can be used by many students. Virtual patients have already been used in Massive Open Online Courses (MOOCs) with close to 20.000 enrolled students [Kononowicz 2015], and with minimal scaling-up costs. You should take into account that alternatives to virtual patient simulation modalities are very expensive. For instance, the time of simulated patients is limited and requires training, salaries and on top of that the experience cannot be shared by many students simultaneously. In another study conducted by Haerling, it was shown that the cost associated with mannequin-based simulation is three times higher than for virtual patients without difference in terms of improvement in knowledge and satisfaction [Haerling 2018].

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