Learning activities around VPs

Guiding question:

What should be the tasks students are supposed to do around virtual patients?

Virtual patients are a great tool to learn clinical reasoning. During the design and integration process different types of activities should be taken into consideration, to allow a meaningful and engaging learning process.

Ellaway and Davies distinguish the following learning activities around the VPs: read unfolding narrative, select appropriate history questions, select management options, make diagnosis, learn underlying medical science through guided discovery (optional), view report and debrief (if logged in) [Ellaway 2011]. Other tasks could be writing a summary statement, creating a concept map, creating a case (learning by teaching strategy), solving a case in an interprofessional team and group discussion.

For example in the CASUS system students are asked to fill in a summary statement, a short presentation of a patient of usually one to three sentences length. It is a synopsis of findings from history taking and physical examination. The ability to present a patient in such a concise way is a good indicator for clinical reasoning skills, because the student has to summarize and synthesize a patient’s information [Bowen 2006]. This also provides a chance to practice clinical semantics. Summary statements can be required any time during the case, but they are particularly relevant for case completion. If the author includes examples of expert summary statements as model examples for students, these can be used to scaffold learning, isolate gaps in domain knowledge and as a powerful tool for formative or summative assessment [Posel 2015].

Important element of VPs are concept maps created by students during the process of working on the case. A concept map is a graphical tool for organizing knowledge and it results in a visible representation of the students’ clinical reasoning on a case, which permits them to identify learning gaps [Penuela-Epalza 2019]. Learning with a use of concept maps creation allows combining lower order concepts with higher order concepts, which then can lead to formation of a hierarchy of knowledge and understanding [Daley 2016].

Another activity to be used around the VPs is to involve students in the creation of the cases. Learners show a positive and highly motivated attitude towards this teaching strategy. In a paper by Hege et al. motivation was attributed in 67% of the students to the interest in case-based training and the effectiveness of this strategy [Hege 2007].

VPs can be also used in activities of interprofessional groups of students. Such solution allow better understanding of the other profession’s scope of practice, tasks and responsibilities. Furthermore, it provides a holistic patient’s perspective through the complementary professional view [Edelbring 2022]. Solving VPs in mixed teams promotes interprofessional teamwork and collaboration. They can share their ideas, decision making and responsibility, which in overall prepares them to work in such clinical teams in real life [Martini19].

As noted by researchers one of the tasks could be also a discussion, where students are comparing two VPs with common differential diagnoses or a combination of similar, but contrasting VPs, where the students are encouraged to consider alternative diagnoses and reflect on key features of each of the VP cases. This improved students’ understanding of disease and helped reflect on differential diagnoses [Cendan 2012, Huwendiek 2013].

Recommendations:
– Add a summary statement as a task allows students to learn how to present a patient in a concise manner as a good indicator of clinical reasoning.
– Provide learning with the use of concept map creation to give students the opportunity to organize information.
– Try out other activities, such as the creation of the VPs by students, working on VPs in interprofessional teams, and discussion on similar but contrasting VPs.

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.