Prioritization / Relevance
- Should the use of virtual patients in the curriculum be mandatory or voluntary?
- How to improve the perceived relevance of virtual patients by students?
- What is localization of virtual patients?
Integration of virtual patients in curricula differ by the weight the faculty put on their use by students. Some universities tend to play safe and introduce virtual patients as voluntary activities. Interested students are recommended to use virtual patients to deepen their knowledge as a self-study in their free time. Other universities make them mandatory which means their completion is a core requirement to obtain course credits. Which of those approaches is better?
There is no simple answer to this question and the evidence for recommendations is limited. What has been consistently observed is that when virtual patients are completely voluntary their use will be very low [Radon 2011, Kim 2018]. In a study by Hege et al., just around 10% of students used virtual patients when they were optional [Hege 2007]. Such behavior of students has been observed in implementation of other types of e-learning and simulation in general as well [Issenberg 2005].
The straightforward solution is to make the use of VP obligatory. This is even expected by some students who admit that they need external motivation to complete them [Huwendiek 2013]. Yet, there is a risk in mandatory integration scenarios. Teachers tend to set completion criteria easy to verify automatically, like minimal percentage of content (e.g. screen cards) displayed, time spent on exercise, success rate in multiple choice questions. But this can lead to superficial learning. There are always students who get tempted to game the system and click mindlessly through the content to reach the required threshold score or exchange answers to questions with other students [Hege 2007]. Kim et al. compared the mandatory and voluntary use of VPs in clinical clerkship and found that students in the mandatory integration mode completed more VPs and spent more time on them [Kim 2018]. Unfortunately, there was neither any difference in objectively measured knowledge by the end of the clerkship nor in student satisfaction which might be interpreted as evidence of superficial learning.
The key to gain educational benefit from VPs seems to be to convince the students about the relevance of virtual patients to succeed in their health professional career [Edelbring 2012]. One way to achieve this is to show them explicitly how the learning objectives of VPs map to the curricular learning objectives. This is already discussed here.
Another solution is to take advantage of the rule that assessment drives learning and make the VPs exam-relevant. It means that the use of VPs remains voluntary, but it is explicitly stated how their content is covered in the examination blueprint. For instance, the teacher may declare that 20% of the questions in the final exam will address topics discussed in the VPs. In the study by Hege et al. more than 90% students used exam-relevant VPs [Hege07]. The result was comparable to the obligatory strategy, but the time the students spent on solving the cases was longer and there were indications of a more in depth approach to learning.
There are also other ways to improve the perceived relevance of the cases by students and by that their usage ratio. One of them is to involve students in the authoring of VPs. This approach is known as the “learning by teaching” strategy [Hege07]. Students often know best what is challenging for them in handling VPs and in collaboration with experts in the field focus on those issues when designing cases, learn from that, and make the VPs more relevant for peer students [Radon11].
Motivation to use VPs is low when students think they are not their target group. This may happen when VPs in the curriculum were developed in a context different to that of the students’ – e.g. as presented in external commercial products purchased by the university or in cases by authors from abroad in international projects [Fors09]. Some of the recommended diagnostic and treatment methods may be different and the cultural background feels foreign. The language of the virtual patients may be a barrier as well. Fors et al. has observed the use of VPs in a group of Romanian students who declared good or very good English skills. The same cases were randomly assigned to students either in English or Romanian language. Despite good declared English skills, students selected more diagnostic tests, made better decisions and spent more time on learning when the cases were available in their mother tongue [Fors09].
The solution to the foreign context problem could be the language and cultural adaptation of VPs when implementing them in the curriculum. Some of the systems allow the content of the VPs to be translated in the native language of the student, which is worth the effort even if students (declare to) have good English skills. Medical tradition and cultural differences can be clarified and commented to the students by local specialists in expert comments connected with the cases. The relevance to know cultural differences can be explained to the students by the growing mobility of patients and medical doctors nowadays [Fors09]. The iCoViP project has developed a workflow to handle the adaptation process and applied it in the development process of the 200 VPs initially designed in English to the local context and language of the 5 participating countries.
What is also very important in convincing students about the relevance of VPs is the positive attitude of their teachers to the cases. Students are skillful in recognizing that. If the teachers disbelieve in the effectiveness of VPs, so will their students. If the teachers say this is just for the “young generation”, the students will doubt they will get feedback in case of problems and the topics presented in VPs will be relevant during their examinations. It is crucial the teachers walk the way they talk: know the content of VPs, are familiar with how to use them, and make reference to them while teaching.