Alignment of VPs with curricular learning objectives

Guiding questions:

How do I align the VPs with the overarching learning objectives of the curriculum?
How do I make selections of the VPs?
How do I modify the VPs to adjust them to those goals?

One of the most important developments in medical education of the last two decades is the movement towards Outcome-Based Education (OBE) [Holmboe 2021]. Curricula designed following this paradigm start with a clear specification of the intended learning outcomes. All the decisions made regarding the curriculum design, in particular selection of the instructional and assessment methods, should be directed towards achieving the pre-specified learning objectives. This is also known as constructive alignment.

Therefore, when introducing VPs into the curriculum it is very important to first identify the learning objectives (LOs) in the curriculum that are suitable to be addressed with VPs. What those relevant learning objectives are depends on many factors including the mission statement and overarching goals of the curriculum at your university. Some countries may be obliged or strongly recommended to implement specific competency frameworks prescribed by various accreditation bodies. Finally, this may depend on LO-specific disciplines [Radon 2011]. Do not forget to consider also the level of competency of students that you want to introduce the VPs to, or user-specific interests (more information about these topics).

The general guideline is to consider VPs as a valid instructional tool to achieve LOs related to clinical reasoning [Cook 2009, Plackett 2022]. VPs come to the rescue when it gets hard to fulfill LOs because of insufficient inpatients covering specific diagnoses. They can work well as an additional learning source in the absence of real patients or clinical teachers, allowing learning to be continued [Tworek 2010]. However, apart from learning about the management of different diseases, there are also other curricular objectives and themes that may be well implemented with VPs. In particular, these could be cultural competencies [Smith 2011], sex- and gender-specific health [Casanova 2019], care for patients with special needs like developmental disabilities [Sanders 2008], empathic communication with patients [Guetterman 2019] or interprofessional collaboration skills [Edelbring 2022].

In an integrated curriculum, VPs can be a useful tool in addressing basic sciences’ LOs for higher motivation to learn it in a clinical context. For instance, while presenting VPs to discuss with the students the pathophysiological mechanisms behind common signs and symptoms you should pay attention to the use of adequate semantic qualifiers. This strategy is likely to facilitate better knowledge encapsulation that leads to more robust clinical reasoning [Woods 2007].

It is also worth emphasizing that VPs are not only suitable for teaching but can also be an assessment method for many LOs [Huwendiek 2008]. We discuss formative and summatice assessment with VPs here. However, we would like to stress here, in particular, that if you address a clinical reasoning LOs (so-called higher level thinking) with VPs and then assess the outcome using a knowledge-based multiple-choice question test alone, you should not be surprised to see modest effects as this is not a good example of constructive alignment. It is important to explicitly communicate to the students how the LOs of your VPs contribute to the overall concept of the curriculum [Hege 2007]. What may help is to map existing VPs to the end-of-program outcomes highlighting where the curriculum objectives will be met, where there is still an option to enhance the learning, and where there are gaps [Altmiller 2021].

If you have the opportunity to edit the VPs, you may wish to adapt them to your particular LOs and target levels of competencies. However, you need to be careful not to lose the authenticity of the VPs, meaning that it should closely relate to the work of the practicing health professional. According to Hirumi et al. (2016), simplifying the interactions within the VP case, will decrease the authenticity, but will also reduce frustration and increase satisfaction with the user interface [Hirumi16]. Furthermore, we have discussed localization of VPs in the section on prioritization of VPs.

Based on the literature and our experiences, there is no defined number of VPs you should put into the curriculum. As the different researchers present their findings, clinical reasoning is problem-specific and there is no generalizable problem-solving algorithm that can be learned [Elstein 1978, Norman 2005]. It means that medical students need to experience in the curriculum a large number of cases with a range of specific medical problems to become competent physicians [Lanphear 2021]. For instance, in one paper, authors have introduced 72 VPs in the renewed curriculum at the University of Toronto [Kulasegaram 2018]. The iCoViP collection contains 200 virtual patients [Mayer 2022]. We underline that the selection of VPs in such collections should be well thought through and should be attempting to resemble the distribution of diseases in the VP collection to that of the target population of real-life patients to avoid introducing bias to the students. The higher the number of cases you have in your collection (more than 15 cases), the higher the mean satisfaction of students will be [Al-Dosari 2017]. But of course, you should always consider your educational setting, curriculum, and LOs when deciding on the number of VPs.

Recommendations:
– VPs need to be “constructively aligned” with overall course objectives.
– VPs are a tool to achieve learning objectives related to clinical reasoning.
– VPs are useful in addressing basic sciences’ learning objectives for higher motivation to learn it in a clinical context.

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.