Presence mode

Guiding questions:

Should students work on VPs in a computer lab, shared space, seminar room or at homes?
If working at distance should it be synchronous or asynchronous?
If a mix of those modes is recommended what should guide the selection of the mode?

When preparing integration of VPs into the curriculum, another important aspect to consider is the presence mode, namely what are the differences (and potential advantages and disadvantages) between working on the VPs on-line or in-person, during classes or using a blended strategy.

In face-to-face settings, students physically are present on the campus to work on the VPs. One of the advantages of this approach is for participants to get to know the computer program they intend to use, for the teacher to introduce important or complex topics [Fischer 2008]. Also specialized solutions such as VPs in virtual reality or in combination with other forms of simulation (e.g. standardized patient, patient simulator etc.) can be implemented that way. Solving VPs cases in the presence of a tutor gives the students higher motivation, especially when content is related to the exam material [Hege 2007], and less distraction when they work the VP cases in the classroom. Students also can receive immediate feedback or guidance when encountering problems during case solving. In interprofessional groups, the learners appreciate face-to-face form as an efficient tool to enrich the discussion and get a meaningful value in the encounter with the other profession [Edelbring 2022]. In the literature, different formats are indicated, depending on the level of curriculum, rooms availability etc. VPs can be introduced as an individual or group laboratory exercise.

Regarding the on-line setting, working on the cases at home allows for self-directed learning at the student’s own pace, and deeper reflection on the material covered during small-group practicals [Riedel 2003]. Depending on the learner’s needs, students can fill in their own knowledge gaps (by reading additional resources) and organize their thoughts (e.g. in the form of a concept map); in this way, learning can be personalized, related to the individual needs rather than the needs of the group.

The online setting can also be used in situations of limited access to learning spaces or restrictions on contact hours [Johnson 2014] as happened during the COVID-19 pandemic or during individual illness, family situation, course of study or more logistic-based problems like conflicts in the study programs for interprofessional training. In this case students prefer an on-line encounter due to flexibility in time and space [Edelbring 2022].

If you are just starting with an on-line learning environment, we need to bear in mind that getting the tutors trained will take some time and this strategy might not be readily available. You can read more about teachers’ training in this section.

A compromise that combines the above techniques is blended learning. VPs may be featured in the both face-to-face, synchronous online (collaborative) and asynchronous online (independent study) elements of an activity [Ellaway 2015].

VPs can aid the delivery of additional content or introduction of a new material in an asynchronous way [Geha 2018]. It has also proven to be a successful theoretical, but practice-oriented preparation before practical implementation of the acquired knowledge (also known as flipped-classroom) [Huwendiek 2008], which allows students to learn in an environment similar to real practice, reducing the stress and a “culture shock” between university and clinical setting [Morrissey 2014].

Blended learning using VPs, however, can also proceed first in face-to-face mode – e.g. during a problem-based learning session – and then on-line as a repetition before an exam or as a reflection after an in-person encounter. It was shown by Kononowicz et al. that students using VPs together with face-to-face sessions were able to gain more from the course and scored better in the knowledge post-test than the control group [Kononowicz 2012].

There is a recommendation that the new curricula should include VPs, because of their utility in distributed learning environments as well as their ability to meet learners’ requirements for asynchronous as well as synchronous on-line learning [Posel 2012]. According to Ellaway et al., VPs have been successfully used as the integrating or scaffolding medium for distributed teaching. In that case, different groups at different sites work first independently, and then come together for collaborative VPs tasks [Ellaway 2015].

The conclusion is that face-to-face and on-line modes can be flexibly and deliberately selected according to the learning objectives and teaching constraints.

Recommendations:
– Using VPs in a face-to-face setting gives an opportunity to introduce them, to have immediate teacher’s feedback and tends to be less distracting and more motivating for students.
– Working with VPs in an online setting allows a self-directed learning and deeper reflection.
– VPs can be also implemented in blended format, when introducing new concepts, delivering additional material, before the exam or clinical encounter, combining pros and cons of both modes, and bringing opportunity for better knowledge acquisition.

Phase of the curriculum	4th year of medical school
Goal in the curriculum	The 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 resources	The 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 alignment	The collection is used while students are doing their clinical placements having a teacher revising the responses and explaining to students most frequent mistakes.
Prioritization/relevance	For 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 activities	None
Time allocation	One week was given to complete the assignment but more time was available for those who wanted to do the activity remote from home.
Group allocation	Students worked alone at home, when the educator discussed the solution of the VP, it was allocated in class (face-to-face or online).
Presence mode	Asynchronous
Technical Integration	It was integrated into Moodle.
VP use orientation/training	VPs 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 infrastructure	We used the technical infrastructure of the iCoViP project without any additions at the University of Zaragoza.
Learning activities around VPs	The teacher explained each VP and how to resolve them after getting the responses of all the students.
Assessment	Students had to complete the VPs, but there was no grade at the end. Only credit (pass/fail).
Quality assurance, maintenance, and sustainability	Frequent revision of the VPs by medical doctors.

Phase of the curriculum	Year 3 and 4 of medical school
Goal in the curriculum	Students 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 resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs
VP alignment	VPs 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 allocation	5 VPs / module
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	No specific familiarization, but general introduction at the beginning of year 3.
Learning activities around VPs	Depending on the modules other learning activities were embedded.
Assessment	The topics of the VPs were part of modules assessment.
Quality assurance, maintenance, and sustainability	We 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 curriculum	Year 1 and 2 of medical school
Goal in the curriculum	Students 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 resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs.
VP alignment	VPs 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 allocation	15 VPs over two years / 5 VPs per module.
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	At the beginning of year 1 students were introduced into clinical reasoning and how they can train this ability with VPs.
Learning activities around VPs	Depending on the key symptoms during the longitudinal clinical course other learning activities were embedded.
Assessment	The topics of the VPs were part of the clinical longitudinal course assessment.
Quality assurance, maintenance, and sustainability	We 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 curriculum	Basic 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 resources	Use 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 activities	We 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 allocation	Around 30 minutes biweekly, repeated 7 times in a semester.
Group allocation	Students 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 mode	Students worked on the VPs asynchronously and self-directed at home to have time to reflect and consult textbooks.
Technical Integration	VPs 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/training	Students 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 infrastructure	Students used their own computers from home. An email address was provided to a person responsible for technical support.
Learning activities around VPs	Students 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.
Assessment	Students 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 sustainability	We 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.