Relation to other learning activities

In this section we will try to focus on situations where we want to introduce VPs as an addition to other, already existing learning activities. What should be the combination and what should it look like?

Any integration process of VPs into the curriculum must be carefully planned, implemented and evaluated. To be successful, e-learning resources like VPs, in particular, must be integrated and aligned with the desired learning objectives [Baumann-Birkbeck 2017] and other teaching events [Haag 2010] like cardiac auscultation exercises on mannequins [Quinn 2011] or radiological course programs [Scherer 2011]. As stated by Huwendiek et al., those activities should be built on each other to give the students an opportunity to apply newly gained knowledge [Huwendiek 2013].

VPs can be used in very different settings. Cases can be included in all learning environments being particularly suitable to small groups, larger interactive classroom teaching sessions and individual learning. VP cases can be used as a prerequisite for high-fidelity simulations [Singh 2003] or may be used as an assessment method of intended learning outcomes. Students prefer to have the VPs introduced after rather than during the lectures, which they call “an incompatible setting” for the experience of working through cases [Dahri 2019]. It is possible to combine communication-focused classes or mannequin-based activities by asking students to solve VPs in preparation for high-fidelity simulation. When students are waiting to take their turn on a simulator or enter a role playing activity, give them a VP to solve, which will allow them to stay active and focused throughout that time. Thereby, you can use the existing resources in a better way, enhance different experiences and turn partial-task training into whole-task training [Ellaway 2015].

As noted by Fischer et al., if we use VPs without integrating them into the curriculum, this would lead to low acceptance of such methods. Therefore, exam-relevance of VPs and integration with follow-up seminars are key factors for a high level of acceptance. Fischer et al. presented an example from Munich where internal medicine learning cases ceased to be integrated on a mandatory basis. Instead, students were provided with 15 learning cases that thematically related to a weekly seminar (with 18 students per group) and dealt with content that was relevant to the final written exam. The learning cases were to be worked on in self-study as preparation for the follow-up seminar and discussed there. About 10% of the questions in the final exam referred to case contents [Fischer 2008].

VPs can also be an addition to simulated patients (SPs). As stated by Cendan et al., this solution gives the students the chance to revise the content, to receive individualized feedback, to reflect on the actions taken during the encounter, and to compare their decisions with the best practices protocols or recommended procedures. VPs can be used, for instance, in a situation where the SP cannot demonstrate some of the elements of physical examination findings like cardiac murmurs, abnormal breath sounds, or neurological deficits [Cendan 2012, Johnson 2013]. They can also be used as preparation before either interacting with an SP, where the given feedback might potentially be a powerful educational tool [Stevens 2006], or with real patients, which can give students more confidence. More about feedback will be covered in this section.

In the literature, recommendations can be found on using VPs alongside traditional clinical placements [Menendez 2015]. There is a strong notion that it should complement the bed-side teaching, making it more understandable and meaningful [Edelbring 2011] and also allowing to link the basic sciences with clinical encounters [Posel 2012]. iCoViP partners recommend that VP activities can be given to students during clinical placements when doctors are unavailable. The lack of availability of patients showing a particular clinical presentation during the clerkship can be compensated by a VP experience as suggested by the Liaison Committee on Medical Education (LCME) ED-2 standard [Tworek 2010]. For instance, it can be used on the last day of the clerkship if there are gaps (VP is better than nothing), or in times when clinical teaching and learning is temporarily impossible (i.e.: during the COVID-19 pandemic) [Nascimento 2021].

When we speak about the relation to other learning activities, a relevant component of VPs integration is to organize a follow-up seminar around this activity. According to Zary et al., teacher-led seminars may still play an important role in providing credibility to the VPs [Zary 2009]. Further advantages are that it gives higher effectiveness for learning in terms of deeper discussion within a safe environment, seems to catalyse the case processing and relates the cases to the clinical reality by virtue of the teacher’s clinical perspective [Edelbring 2012].

One of the challenges you may face when introducing VPs into the curriculum is that it cannot be stretched more and some elements will need to be removed to make space for using VPs. But what to choose to not compromise the overall objectives? The current literature reflects this struggle.

If you need to make a decision about removing activities from an existing curriculum to make space for VPs, it is better to replace passive forms of teaching - like lectures or reading exercises - instead of active methods like small group discussions or mannequin-based learning [ Kononowicz 2019]. At the same time some authors remind us that if you uncritically remove some teaching activity, this would not necessarily improve neither the perceived integration nor the learning [Berman 2009, Lang 2013].

With CoViP partners we discussed that a replacement should not be radical and involve a complete withdrawal of an established teaching format for the benefit of VPs rather it should have the form of a partial replacement. For instance, even though lectures have limitations, they still have their role in introducing key knowledge concepts. Yet, the replacement of static case presentations within lectures with VPs was regarded as a reasonable solution. In our iCoViP project discussion around the guidelines the opinion was often voiced that the beauty of teaching comes from preserving diversity of suitable teaching methods.

If you already work with traditional paper-based cases, there is a recommendation to replace them with virtual cases [Cendan 2012]. In a study by Poulton et al. the replacement of paper-based cases by online VPs in PBL sessions was highly appreciated by both students and teachers. Also, students and tutors think that interactive VPs provide a more authentic, immersive experience suited to problem solving [Poulton 2011]. Furthermore, compared to reading a book, the use of VPs was found to trigger higher student engagement, and having an extra dimension with the use of video clips of patient presentations. VPs are also a valuable tool in terms of time-efficiency compared to real patients’ interactions or case seminars as well as variation in learning activities, studying “in a different way” as compared to traditional methods [Edelbring 2011].

Students also express preference of VPs over traditional knowledge transfer solutions such as lectures [Dahri 2019, Kolb 2007]. When they have a chance to independently work with VPs (e.g instead of going to lectures), they have the opportunity to self-assess their diagnostic and patient management skills [Ellaway 2011]. According to one of the studies, 78% of students indicated that replacing lectures with virtual patients allowed for better use of faculty contact time with them and 84% of them said that completing the virtual patient prior to class allowed them to become better self-directed learners [Benedict 2013]. Also, it was important to students during clinical clerkships to have some activities removed in order to deal with the additional workload created by the integration of VPs [Huwendiek 2013].

Choosing to move to VPs could solve problems related to financial constraints on materials [Maleck 2001]. The paper-based medium itself can put a strain on tutors: lack of accessibility, the cost and time resources to replicate the patient’s imaging and other materials needed for the paper-based cases. Thanks to moving to VPs we may improve the delivery of patient cases [Zary 2009] and save some resources, while still increasing learning opportunities [Doloca 2016]. As one of our students once summarized about working on a VP module: "you do not have to copy it and you cannot lose it" [Kononowicz 2012]. There is also a strong recommendation to never replace real patient contacts with VPs, unless it is absolutely necessary, which for example we have observed during full lockdown because of the COVID-19 pandemic.In this particular situation, it was done more as a complement than a real replacement. The same applies to situations where the healthcare setting does not provide a patient matching our learning objectives. VPs could complement areas where there are no other suitable learning tools for clinical reasoning and problem solving [Poulton 2011]. Moreover, VPs could be a learning tool directed into a specific task [Edelbring 2011].

In general, when VPs are integrated into existing learning activities or used to replace such activities, the perceived implementation seems to be more successful than when redundant traditional methods are kept in place [Berman 2009] or when VPs are used as additional activities on top of the existing curriculum [Lang 2013].

When you are considering implementation of the VPs in relation to other learning activities, one more factor should be taken into account. It is how we will sequence the VPs with other teaching events. Should they be presented in a specific order (including time spaces between the activities), and what could it be?

Most importantly, try to be flexible in sequencing VPs depending on your needs and the needs of your students, as well as the learning objectives you would like to achieve. It was found that spaced activation contributed to a more balanced (spreaded in time) use of VPs with a lower peak of number of sessions right before the exam [Maier 2013].

If you are considering using the VPs with lectures, you could introduce them before the lecture to activate students’ knowledge; or after - to reinforce it. For instance, in the study of Huwendiek et al. 2013 students preferred working on VPs after the lectures, as it enabled them to apply knowledge from the lecture to the VP. This had another function, it raised students’ confidence and helped them memorize important aspects [Huwendiek 2013]. According to the majority of students (78%), completing the VPs before the class gives an opportunity to use the class time for activities more difficult to complete at distance as hands-on-training or small group discussion, and therefore it stimulates self-directed learning [Baumann-Birkbeck 2017].

In the case of bedside teaching, VPs can be used also in two ways: before meeting a real patient - to gain confidence; or after - for reflection or to discuss errors. As noted by Huwendiek et al. 2013, according to students, it was highly meaningful, motivating and supportive for their learning to work on a VP before an encounter with a real patient with similar symptoms. This made them feel ready and confident to engage in these encounters. Students can plan which questions to ask, what kind of examinations to perform and which differential diagnoses to take into consideration [Huwendiek 2013].

What also may be beneficial, is to let the students work on VPs independently at home, so they can develop their problem-solving skills, and then follow it up with a tutorial with the teacher, where students can sum up their learning, revisit the case, as well as get answers to all of the questions, that may have arisen. Between these two meetings, interdisciplinary lectures use the case as a spring board to cover relevant concepts [Kulasegaram 2018]. Riedel et al. 2003 found that the scenario where first students work in a group of 2-3 per one computer, with the tutor present in the class, and then learn alone at home - was assessed as the best implementation method [Riedel 2003]. There is also another aspect of organizing small group discussions after individual work on VPs. It was found that students take such a solution more seriously, when they know that they are likely to be questioned about the VPs [Huwendiek 2013].

Most probably, there is no one best solution in terms of sequencing when using the VPs. Generally, it is believed that if you sequence a lecture, followed by one or two VPs, then organize a small group discussion and finalize with a real patient encounter, this will give a student maximum support for their learning and optimal preparation [Huwendiek 2013]. Similar recommendation was given by Hirumi et al. 2016 where the integration strategy included a lecture, a demonstration of NERVE [a digital learning environment around cranial nerve disorders knowledge] with explicit expectations and requirements, VPs interactions within the NERVE, an instructor-led AAR [After Action Review, i.e. follow-up seminar] with the entire class, and a standardized patient/virtual patient (SP/VP) hybrid encounter [Hirumi 2016].